MEDICARE: ANNA KETCHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	COA.17080-NP	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000966352	OTHER	OH	ANTHEM BC/BS

General Provider Information

NPI Number	:	1669859229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA KETCHAM

Provider Business Mailing Address
First Line	:	3572 DAYTON-XENIA RD.
Second Line	:	STE. 105
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2838
Country	:	US
Telephone Number	:	937-427-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	3572 DAYTON XENIA RD
Second Line	:	SUITE 105
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2886
Country	:	US
Telephone Number	:	937-427-4600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2015
Last Update Date	:	06/08/2017

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Directions to “ ANNA KETCHAM ” Practice Location

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