Provider Demographics
NPI:1760750376
Name:BASS, TINA ROSE (RN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ROSE
Last Name:BASS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 SW BAOY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3813
Mailing Address - Country:US
Mailing Address - Phone:772-216-0770
Mailing Address - Fax:
Practice Address - Street 1:4500 W MIDWAY RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4823
Practice Address - Country:US
Practice Address - Phone:772-672-8481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9301212163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult