Provider Demographics
NPI:1245615020
Name:KETCHAM, JUDY HWANG (RN, FNP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:HWANG
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:CHIANYIAO
Other - Last Name:HWANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3131 BERGER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4233
Mailing Address - Country:US
Mailing Address - Phone:352-359-2682
Mailing Address - Fax:
Practice Address - Street 1:3131 BERGER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4233
Practice Address - Country:US
Practice Address - Phone:858-244-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily