Healthcare Provider Details

I. General information

NPI: 1689633489
Provider Name (Legal Business Name): BEVERLY E KETCHEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CITY HALL MALL
MEDFORD MA
02155-4754
US

IV. Provider business mailing address

26 CITY HALL MALL
MEDFORD MA
02155-4754
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-5100
  • Fax:
Mailing address:
  • Phone: 781-306-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number110231
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number110231
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: