Provider Demographics
NPI:1669859229
Name:KETCHAM, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3572 DAYTON-XENIA RD.
Mailing Address - Street 2:STE. 105
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2838
Mailing Address - Country:US
Mailing Address - Phone:937-427-4600
Mailing Address - Fax:
Practice Address - Street 1:3572 DAYTON XENIA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2886
Practice Address - Country:US
Practice Address - Phone:937-427-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17080-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000966352OtherANTHEM BC/BS
OHH337021Medicare PIN