Provider Demographics
NPI:1245602606
Name:KETTERINGHAM, CARYN (PMHNP)
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:KETTERINGHAM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAFAYETTE ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4116
Mailing Address - Country:US
Mailing Address - Phone:212-369-6757
Mailing Address - Fax:212-369-3941
Practice Address - Street 1:110 LAFAYETTE ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4116
Practice Address - Country:US
Practice Address - Phone:212-369-6757
Practice Address - Fax:212-369-3941
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401718363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health