Provider Demographics
NPI:1750767356
Name:KETCHAM, KELLY ANN (RN, CPHQ)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:RN, CPHQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-2212
Mailing Address - Country:US
Mailing Address - Phone:845-794-8830
Mailing Address - Fax:
Practice Address - Street 1:69 RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-2212
Practice Address - Country:US
Practice Address - Phone:845-794-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328558163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse