Provider Demographics
NPI:1952488454
Name:KETTERIDGE, MARTHA L (NP)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:L
Last Name:KETTERIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:L
Other - Last Name:OUTCAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:STE 5
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2979
Mailing Address - Country:US
Mailing Address - Phone:631-864-1795
Mailing Address - Fax:631-864-1795
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:STE 5
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2979
Practice Address - Country:US
Practice Address - Phone:631-864-1795
Practice Address - Fax:631-864-1795
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400635364SP0808X
FLF400635363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP90466Medicare UPIN