Provider Demographics
NPI:1497809446
Name:FLUECK, KELLY BASLER
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BASLER
Last Name:FLUECK
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 1:4824 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7036
Mailing Address - Country:US
Mailing Address - Phone:513-205-6983
Mailing Address - Fax:
Practice Address - Street 1:4824 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-7036
Practice Address - Country:US
Practice Address - Phone:513-205-6983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC82885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105397307799Medicaid