Provider Demographics
NPI:1700907565
Name:SMITH BASS, RHONDA FELECIA (CERTIFIED NURSE PRAC)
Entity Type:Individual
Prefix:MRS
First Name:RHONDA
Middle Name:FELECIA
Last Name:SMITH BASS
Suffix:
Gender:F
Credentials:CERTIFIED NURSE PRAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 LARONA RD
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426
Mailing Address - Country:US
Mailing Address - Phone:937-854-6514
Mailing Address - Fax:937-708-5428
Practice Address - Street 1:1055 N BICKETT RD
Practice Address - Street 2:
Practice Address - City:WILBU FORCE
Practice Address - State:OH
Practice Address - Zip Code:45384
Practice Address - Country:US
Practice Address - Phone:937-708-5507
Practice Address - Fax:937-708-5428
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH210745163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2401047Medicaid
OH328140OtherANTHEM BC
P58865Medicare UPIN
OH2401047Medicaid