Healthcare Provider Details

I. General information

NPI: 1649195553
Provider Name (Legal Business Name): EMILY KETCHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

1411 LANEY WALKER BLVD AN-2112
AUGUSTA GA
30912-0002
US

V. Phone/Fax

Practice location:
  • Phone: 762-375-3241
  • Fax:
Mailing address:
  • Phone: 762-375-3241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License NumberRPH031967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: