Provider Demographics
NPI:1629844253
Name:BASS, JAVANTAE
Entity Type:Individual
Prefix:
First Name:JAVANTAE
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SW HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-2580
Mailing Address - Country:US
Mailing Address - Phone:346-300-8332
Mailing Address - Fax:
Practice Address - Street 1:1105 SW HENDERSON ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-2580
Practice Address - Country:US
Practice Address - Phone:346-300-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANA61393862376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide