Healthcare Provider Details

I. General information

NPI: 1588080501
Provider Name (Legal Business Name): ALICIA HAGENAU KETCHUM ARNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEDICAL BLVD STE 102
SPRING HILL FL
34609-0220
US

IV. Provider business mailing address

14690 SPRING HILL DR STE 100 ATTN:CREDENTIALING
SPRING HILL FL
34609-8102
US

V. Phone/Fax

Practice location:
  • Phone: 352-686-0086
  • Fax: 352-684-2081
Mailing address:
  • Phone: 352-799-0046
  • Fax: 352-606-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9278289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: