Healthcare Provider Details

I. General information

NPI: 1598319642
Provider Name (Legal Business Name): CODY LEE BACH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 E WASHINGTON BLVD
CRESCENT CITY CA
95531-8397
US

IV. Provider business mailing address

PO BOX 92227
LAS VEGAS NV
89193-2227
US

V. Phone/Fax

Practice location:
  • Phone: 775-322-4550
  • Fax: 775-322-4956
Mailing address:
  • Phone: 775-322-4550
  • Fax: 775-322-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0994785
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: