Healthcare Provider Details

I. General information

NPI: 1235869959
Provider Name (Legal Business Name): DESTINEE BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 12/05/2023
Certification Date: 06/08/2022
Deactivation Date: 11/08/2023
Reactivation Date: 12/05/2023

III. Provider practice location address

10270 E TARON DR APT 240
ELK GROVE CA
95757-8244
US

IV. Provider business mailing address

4905 STOCKTON BLVD # 101
SACRAMENTO CA
95820-5405
US

V. Phone/Fax

Practice location:
  • Phone: 916-895-4900
  • Fax:
Mailing address:
  • Phone: 916-895-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: