Provider Demographics
NPI:1265869937
Name:BASCOM, KELLY N
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:N
Last Name:BASCOM
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 1:44979 15TH ST WEST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-264-8235
Mailing Address - Fax:661-802-4727
Practice Address - Street 1:44979 15TH ST WEST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-264-8235
Practice Address - Fax:661-802-4727
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVM147196164W00000X, 164X00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No347C00000XTransportation ServicesPrivate Vehicle