Provider Demographics
NPI:1619330677
Name:KETCH, COURTNEY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:KETCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 EUCLID AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2981
Mailing Address - Country:US
Mailing Address - Phone:619-267-8313
Mailing Address - Fax:
Practice Address - Street 1:655 EUCLID AVE STE 409
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2981
Practice Address - Country:US
Practice Address - Phone:619-267-8313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA168350207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA168350OtherCA LICENSE