Provider Demographics
NPI:1134670201
Name:BASS, LATORIA J
Entity Type:Individual
Prefix:
First Name:LATORIA
Middle Name:J
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 1:201 MONROE ST
Mailing Address - Street 2:SUITE 1350
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104-3735
Mailing Address - Country:US
Mailing Address - Phone:334-206-5675
Mailing Address - Fax:334-206-3998
Practice Address - Street 1:1801 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-6861
Practice Address - Country:US
Practice Address - Phone:334-745-5765
Practice Address - Fax:334-745-9830
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-144026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily