Provider Demographics
NPI:1194357665
Name:BARBERO, KELSEY R (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:R
Last Name:BARBERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:R
Other - Last Name:FOUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1215 VANDALIA ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4060
Mailing Address - Country:US
Mailing Address - Phone:618-343-6015
Mailing Address - Fax:618-578-5759
Practice Address - Street 1:1215 VANDALIA ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4060
Practice Address - Country:US
Practice Address - Phone:618-343-6015
Practice Address - Fax:618-578-5759
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant