Provider Demographics
NPI:1720564636
Name:BASS, AMY L (LPN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:BASS
Suffix:
Gender:F
Credentials:LPN
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 235
Mailing Address - Street 2:
Mailing Address - City:DOWNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13755-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28174 STATE HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:DOWNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13755
Practice Address - Country:US
Practice Address - Phone:607-348-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10-326258164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse