Provider Demographics
NPI:1609435239
Name:BASS, KATHY DENESE
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:DENESE
Last Name:BASS
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 170
Mailing Address - Street 2:
Mailing Address - City:INTERLACHEN
Mailing Address - State:FL
Mailing Address - Zip Code:32148-0170
Mailing Address - Country:US
Mailing Address - Phone:386-684-0195
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 170
Practice Address - Street 2:
Practice Address - City:INTERLACHEN
Practice Address - State:FL
Practice Address - Zip Code:32148-0170
Practice Address - Country:US
Practice Address - Phone:386-684-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNP-APRN11000137363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology