MEDICARE: ALEXANDRA NICOLE DIBASILIO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	R249243	MD

General Provider Information

NPI Number	:	1013640093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA NICOLE DIBASILIO

Provider Business Mailing Address
First Line	:	315 POPE AVE APT 8
Second Line	:
City	:	FORT LEAVENWORTH
State	:	KS
Zip	:	66027-1383
Country	:	US
Telephone Number	:	410-960-5206
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 POPE AVE APT 8
Second Line	:
City	:	FORT LEAVENWORTH
State	:	KS
Zip	:	66027-1383
Country	:	US
Telephone Number	:	410-960-5206
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2022
Last Update Date	:	07/06/2022

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