Provider Demographics
NPI:1912229428
Name:KETCHERSIDE, MEGAN A (APP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:KETCHERSIDE
Suffix:
Gender:F
Credentials:APP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:A
Other - Last Name:BINKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-5027
Mailing Address - Fax:
Practice Address - Street 1:108 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-8515
Practice Address - Country:US
Practice Address - Phone:217-443-0416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021609363LF0000X, 363LF0000X
IL041.376402163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse