Provider Demographics
NPI:1619780277
Name:KETCHAM, TAMARA S
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 S 219TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3334
Mailing Address - Country:US
Mailing Address - Phone:402-830-5207
Mailing Address - Fax:
Practice Address - Street 1:5509 N 178TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-2294
Practice Address - Country:US
Practice Address - Phone:402-957-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty