Provider Demographics
NPI:1659577526
Name:FORDHAM-BASS, LORI A (ARNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:FORDHAM-BASS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CLINT MOORE RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2658
Mailing Address - Country:US
Mailing Address - Phone:561-989-9002
Mailing Address - Fax:561-994-9135
Practice Address - Street 1:1905 CLINT MOORE RD
Practice Address - Street 2:SUITE 215
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2658
Practice Address - Country:US
Practice Address - Phone:561-989-9002
Practice Address - Fax:561-994-9135
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2151952363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4233ZMedicare ID - Type Unspecified