Provider Demographics
NPI:1326552415
Name:BASS, MARQUISE MENGUE (GNA, MT)
Entity Type:Individual
Prefix:
First Name:MARQUISE
Middle Name:MENGUE
Last Name:BASS
Suffix:
Gender:F
Credentials:GNA, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 DARLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1319
Mailing Address - Country:US
Mailing Address - Phone:443-762-1052
Mailing Address - Fax:
Practice Address - Street 1:1652 DARLEY AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1319
Practice Address - Country:US
Practice Address - Phone:443-762-1052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMT0104855374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide