Provider Demographics
NPI:1235616244
Name:BASDON, NICOLE AMBER
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:AMBER
Last Name:BASDON
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 1:75 BANTING DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-1460
Mailing Address - Country:US
Mailing Address - Phone:937-378-4811
Mailing Address - Fax:937-378-4812
Practice Address - Street 1:75 BANTING DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-1460
Practice Address - Country:US
Practice Address - Phone:927-378-4811
Practice Address - Fax:937-378-4812
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator