Healthcare Provider Details

I. General information

NPI: 1407308117
Provider Name (Legal Business Name): ERICA DANIELLE KETCHUM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ERICA KIETZMAN

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 E US HIGHWAY 30
MERRILLVILLE IN
46410-5810
US

IV. Provider business mailing address

4420 E 61ST AVE
HOBART IN
46342-6517
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-0900
  • Fax:
Mailing address:
  • Phone: 219-617-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28167043A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71006700A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: