Basic Information
| Provider Information | |||||||||
| NPI: | 1588080501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETCHUM | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | HAGENAU | ||||||||
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| Credential: | ARNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DR | ||||||||
| Address2: | STE 100 ATTN:CREDENTIALING | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346098102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527990046 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MEDICAL BLVD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346090220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526860086 | ||||||||
| FaxNumber: | 3526842081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2014 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9278289 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 016886300 | 05 | FL | MEDICAID |