Provider Demographics
NPI:1457588865
Name:KETCHAM, JODY L (RNC)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 FIDDLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05733-9579
Mailing Address - Country:US
Mailing Address - Phone:802-989-1188
Mailing Address - Fax:
Practice Address - Street 1:1643 FIDDLE HILL RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:VT
Practice Address - Zip Code:05733-9579
Practice Address - Country:US
Practice Address - Phone:802-989-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY591149-1163W00000X
VT026.0031487163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse