Provider Demographics
NPI:1881970929
Name:BASDEN, JOHNETTE
Entity type:Individual
Prefix:
First Name:JOHNETTE
Middle Name:
Last Name:BASDEN
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 1:58 WESTVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1018
Mailing Address - Country:US
Mailing Address - Phone:617-412-6504
Mailing Address - Fax:
Practice Address - Street 1:58 WESTVILLE ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1018
Practice Address - Country:US
Practice Address - Phone:617-412-6504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN66263164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse