Provider Demographics
NPI:1891762647
Name:BASILE-FILLER, MARY J (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:BASILE-FILLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:514 AMERICAS WAY
Mailing Address - Street 2:4603
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719-7600
Mailing Address - Country:US
Mailing Address - Phone:619-435-9970
Mailing Address - Fax:
Practice Address - Street 1:807 E AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2155
Practice Address - Country:US
Practice Address - Phone:619-435-9970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12116363L00000X
CA242214163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse