Provider Demographics
NPI:1932689429
Name:BASS, CRYSTAL RICHARDS (RN)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:RICHARDS
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 1:115 K D REVELL RD
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-2051
Mailing Address - Country:US
Mailing Address - Phone:863-773-4161
Mailing Address - Fax:
Practice Address - Street 1:830 ALTMAN RD
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-9453
Practice Address - Country:US
Practice Address - Phone:863-773-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9234842163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse