Healthcare Provider Details

I. General information

NPI: 1144820085
Provider Name (Legal Business Name): KAYLEEN BINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N MAIN ST
DAYTON OH
45415-3154
US

IV. Provider business mailing address

6300 N MAIN ST
DAYTON OH
45415-3154
US

V. Phone/Fax

Practice location:
  • Phone: 937-275-1500
  • Fax:
Mailing address:
  • Phone: 937-674-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN.430505
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: