Healthcare Provider Details

I. General information

NPI: 1003095142
Provider Name (Legal Business Name): CHRISTINE M BASS RN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 N FERDON BLVD
CRESTVIEW FL
32536-1751
US

IV. Provider business mailing address

221 HOSPITAL DR NE
FORT WALTON BEACH FL
32548-5066
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-7177
  • Fax: 850-689-7332
Mailing address:
  • Phone: 850-833-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN9188227
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: