Healthcare Provider Details

I. General information

NPI: 1114780004
Provider Name (Legal Business Name): CHRISENIE BRUSHA BASS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

IV. Provider business mailing address

218 WHISPER LN
MIDLAND CITY AL
36350-7042
US

V. Phone/Fax

Practice location:
  • Phone: 850-638-1610
  • Fax:
Mailing address:
  • Phone: 334-695-0782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11030993
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: