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General NPI Number Information
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NPI Number | 1699786962
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Entity Type | Individual
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Provider Name | TIFFANY KETCHAM DO
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Gender | Female
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 02/20/2024
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Provider Practice Location Address
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Address Line | 825 NE GATEWAY DR STE 148
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City | GRIMES
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State | IA
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Zip | 50111-1307
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Country | US
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Telephone | 515-875-9607
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Fax | 515-875-9608
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Provider Business Mailing Address
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Address Line | PO BOX 424
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City | DES MOINES
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State | IA
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Zip | 50302-0424
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Country | US
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Telephone | 515-875-9925
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Fax | 515-875-9923
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 03239
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License Number State | IA
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