Provider Demographics
NPI:1841574308
Name:BASSOUM, SHIRLEY KAYE
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:KAYE
Last Name:BASSOUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 TYLERSVILLE RD LOT 90
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF INDIAN SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45015-3304
Mailing Address - Country:US
Mailing Address - Phone:513-376-4957
Mailing Address - Fax:
Practice Address - Street 1:2702 TYLERSVILLE RD LOT 90
Practice Address - Street 2:
Practice Address - City:VILLAGE OF INDIAN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45015-3304
Practice Address - Country:US
Practice Address - Phone:513-376-4957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1219Medicaid
OH2138930Medicaid