Provider Demographics
NPI:1285993360
Name:BAILEY, BRIAN KEITH (LPN)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:BAILEY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-2134
Mailing Address - Country:US
Mailing Address - Phone:920-912-7855
Mailing Address - Fax:
Practice Address - Street 1:1833 N 25TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-2134
Practice Address - Country:US
Practice Address - Phone:920-912-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3141264031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse