Healthcare Provider Details

I. General information

NPI: 1861112484
Provider Name (Legal Business Name): PENNY KETCHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COLONY DR
SAN LUIS OBISPO CA
93409-0001
US

IV. Provider business mailing address

720 ORCHARD DR
PASO ROBLES CA
93446-2300
US

V. Phone/Fax

Practice location:
  • Phone: 805-547-7900
  • Fax:
Mailing address:
  • Phone: 805-975-6828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: