Provider Demographics
NPI:1184905283
Name:BASS, KRISTY (ARNP)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
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 1:1278 N LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2964
Mailing Address - Country:US
Mailing Address - Phone:803-774-4500
Mailing Address - Fax:803-774-4626
Practice Address - Street 1:1278 N LAFAYETTE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2964
Practice Address - Country:US
Practice Address - Phone:803-774-4500
Practice Address - Fax:803-774-4626
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4072363LF0000X
SC18516363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2747Medicaid
SCSC2970F694Medicare PIN