Provider Demographics
NPI:1922137850
Name:BASHAM, KELLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:BASHAM
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:PO BOX 2609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2609
Mailing Address - Country:US
Mailing Address - Phone:270-769-1601
Mailing Address - Fax:270-765-7274
Practice Address - Street 1:108 NEW GLENDALE RD
Practice Address - Street 2:LINCOLN TRAIL DISTRICT HEALTH DEPT
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42702-2609
Practice Address - Country:US
Practice Address - Phone:270-769-1601
Practice Address - Fax:270-765-7274
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1084962163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management