Provider Demographics
NPI:1790008191
Name:BASS, MARCIA B (ARNP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:B
Last Name: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 1:1211 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-2037
Mailing Address - Country:US
Mailing Address - Phone:850-584-2141
Mailing Address - Fax:850-838-2140
Practice Address - Street 1:1702 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348
Practice Address - Country:US
Practice Address - Phone:850-584-2141
Practice Address - Fax:850-838-2140
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9176944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001943000Medicaid