Provider Demographics
NPI:1447019690
Name:BASS, ANNALYCE (NP-BC)
Entity type:Individual
Prefix:
First Name:ANNALYCE
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 LITTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7235
Mailing Address - Country:US
Mailing Address - Phone:404-556-7108
Mailing Address - Fax:
Practice Address - Street 1:745 GLYNN ST S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2049
Practice Address - Country:US
Practice Address - Phone:770-719-5490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA327997363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
568946544OtherBCBS
DC236Medicaid
5874OtherHEALTH PARTNERS