Provider Demographics
NPI:1104503259
Name:BASILIO, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:BASILIO
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 1:1328 CARRIAGE HILL DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-3248
Mailing Address - Country:US
Mailing Address - Phone:740-818-6735
Mailing Address - Fax:
Practice Address - Street 1:1328 CARRIAGE HILL DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-3248
Practice Address - Country:US
Practice Address - Phone:740-818-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty