Provider Demographics
NPI:1437445962
Name:BAJILLAN, KELLEY JO (NP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:JO
Last Name:BAJILLAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 QUAKER LN
Mailing Address - Street 2:STE. 207C
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3832
Mailing Address - Country:US
Mailing Address - Phone:336-883-2500
Mailing Address - Fax:
Practice Address - Street 1:5826 SAMET DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-3660
Practice Address - Country:US
Practice Address - Phone:336-878-6540
Practice Address - Fax:336-878-6541
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC182481363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437445962Medicaid
VA1437445962Medicaid