Provider Demographics
NPI:1689345365
Name:KETCHAM, SUSAN ADELE (MSN RN AGCNS-BC CPAN)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:ADELE
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:MSN RN AGCNS-BC CPAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 TIMBER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:ZION CROSSROADS
Mailing Address - State:VA
Mailing Address - Zip Code:22942-6981
Mailing Address - Country:US
Mailing Address - Phone:617-283-1502
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-297-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182547364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health