Healthcare Provider Details

I. General information

NPI: 1952488454
Provider Name (Legal Business Name): MARTHA L KETTERIDGE N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHA L OUTCAULT N.P

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MAIN ST STE 5
HUNTINGTON NY
11743-2979
US

IV. Provider business mailing address

210 E MAIN ST STE 5
HUNTINGTON NY
11743-2979
US

V. Phone/Fax

Practice location:
  • Phone: 631-864-1795
  • Fax: 631-864-1795
Mailing address:
  • Phone: 631-864-1795
  • Fax: 631-864-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberF400635
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF400635
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: