Provider Demographics
NPI:1235600404
Name:KECKLER, BAILEY JO
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:JO
Last Name:KECKLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:JO
Other - Last Name:HENINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0860
Mailing Address - Country:US
Mailing Address - Phone:605-295-3497
Mailing Address - Fax:
Practice Address - Street 1:24337 US HIGHWAY 212
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-7770
Practice Address - Country:US
Practice Address - Phone:605-964-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR047564163W00000X
SDCP002540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse