Provider Demographics
NPI:1881868420
Name:BASS, BERNICE JANELLE (RD,LD/N)
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:JANELLE
Last Name:BASS
Suffix:
Gender:F
Credentials:RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 GOLFVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-6703
Mailing Address - Country:US
Mailing Address - Phone:863-519-7900
Mailing Address - Fax:863-519-7696
Practice Address - Street 1:2020 E GEORGIA ST
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-6709
Practice Address - Country:US
Practice Address - Phone:863-519-7542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3075133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8278ZMedicare PIN