Provider Demographics
NPI:1356739767
Name:BASA, MARIE SHYRELL (FNP - BC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:SHYRELL
Last Name:BASA
Suffix:
Gender:F
Credentials:FNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10710 ASHWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2648
Mailing Address - Country:US
Mailing Address - Phone:562-712-6354
Mailing Address - Fax:
Practice Address - Street 1:15975 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1303
Practice Address - Country:US
Practice Address - Phone:714-546-6575
Practice Address - Fax:714-551-9411
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA673060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily