Healthcare Provider Details

I. General information

NPI: 1689345365
Provider Name (Legal Business Name): SUSAN ADELE KETCHAM MSN RN AGCNS-BC CPAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

152 TIMBER RIDGE LN
ZION CROSSROADS VA
22942-6981
US

V. Phone/Fax

Practice location:
  • Phone: 434-297-6016
  • Fax:
Mailing address:
  • Phone: 617-283-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number0024182547
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: