Provider Demographics
NPI:1144618158
Name:KETCHAM, KELLY (MED, ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-0356
Mailing Address - Country:US
Mailing Address - Phone:530-409-4424
Mailing Address - Fax:
Practice Address - Street 1:5900 ELVAS AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-4341
Practice Address - Country:US
Practice Address - Phone:530-409-4424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-27
Last Update Date:2014-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer