Provider Demographics
NPI:1417341454
Name:BASSHAM, BRITTNAY RAE
Entity Type:Individual
Prefix:
First Name:BRITTNAY
Middle Name:RAE
Last Name:BASSHAM
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 1896
Mailing Address - Street 2:NONE
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-0030
Mailing Address - Country:US
Mailing Address - Phone:228-219-2155
Mailing Address - Fax:
Practice Address - Street 1:101 N FRANKLIN ST
Practice Address - Street 2:NONE
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36602-2505
Practice Address - Country:US
Practice Address - Phone:228-219-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8779664390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program