Provider Demographics
NPI:1235869959
Name:BASS, DESTINEE
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:
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 1:4905 STOCKTON BLVD # 101
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-5405
Mailing Address - Country:US
Mailing Address - Phone:916-895-4900
Mailing Address - Fax:
Practice Address - Street 1:10270 E TARON DR APT 240
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-8244
Practice Address - Country:US
Practice Address - Phone:916-895-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-12-05
Deactivation Date:2023-11-08
Deactivation Code:
Reactivation Date:2023-12-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula