Provider Demographics
NPI:1750638433
Name:KETCHUM, ALICIA (LPN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEW HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:PAINTED POST
Mailing Address - State:NY
Mailing Address - Zip Code:14870-9326
Mailing Address - Country:US
Mailing Address - Phone:607-684-8825
Mailing Address - Fax:
Practice Address - Street 1:3 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9326
Practice Address - Country:US
Practice Address - Phone:607-684-8825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305453251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health