Provider Demographics
NPI:1518979855
Name:SMITH- BASSETT, AMY LOUISE (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:SMITH- BASSETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5251
Mailing Address - Country:US
Mailing Address - Phone:860-533-0179
Mailing Address - Fax:
Practice Address - Street 1:74 PARK RD STE 2
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1898
Practice Address - Country:US
Practice Address - Phone:860-533-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041299719363L00000X
IL209004736367A00000X
CT000333367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041299719OtherPROFESSIONAL NURSE LISCEN
IL209004736OtherADVANCED PRACTICE NURSE
CT009003336Medicaid
IL309002077OtherCONTROLLED SUBSTANCE
CTD400005870 - C00023Medicare PIN
IL041299719OtherPROFESSIONAL NURSE LISCEN