MEDICARE: MRS. RHONDA FELECIA SMITH BASS CERTIFIED NURSE PRAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	210745	OH
2	363L00000X	Nurse Practitioner	210745	OH
3	364SP0812X	Community Psychiatric/Mental Health Clinical Nurse Specialist	RN.210745	OH
4	363LC1500X	Community Health Nurse Practitioner	RN.210745	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	328140	OTHER	OH	ANTHEM BC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	492320001	OTHER	OH	CARE SOURCE

General Provider Information

NPI Number	:	1700907565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RHONDA FELECIA SMITH BASS CERTIFIED NURSE PRAC

Provider Business Mailing Address
First Line	:	1101 LARONA RD
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426
Country	:	US
Telephone Number	:	937-854-6514
Fax Number	:	937-708-5428

Provider Business Practice Location Address
First Line	:	2720 E 3RD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-2102
Country	:	US
Telephone Number	:	937-520-7889
Fax Number	:	376-303-6039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	12/30/2024

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