Healthcare Provider Details

I. General information

NPI: 1538806476
Provider Name (Legal Business Name): KARA DIANA KETCHNER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARA KETCHNER

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 VERANDAH DR STE AANDB
AUGUSTA GA
30909-5608
US

IV. Provider business mailing address

3604 VERANDAH DR STE AANDB
AUGUSTA GA
30909-5608
US

V. Phone/Fax

Practice location:
  • Phone: 706-250-0425
  • Fax: 762-320-5338
Mailing address:
  • Phone: 706-250-0425
  • Fax: 762-320-5338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP026558A
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-014325
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: