Provider Demographics
NPI:1407611858
Name:BASS, SHELLY CORINNE (FNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:CORINNE
Last Name:BASS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MORRIS CIR
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 MORRIS CIR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1438
Practice Address - Country:US
Practice Address - Phone:252-339-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023169071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty