Healthcare Provider Details

I. General information

NPI: 1609435239
Provider Name (Legal Business Name): MRS. KATHY DENESE BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 170
INTERLACHEN FL
32148-0170
US

IV. Provider business mailing address

PO BOX 170
INTERLACHEN FL
32148-0170
US

V. Phone/Fax

Practice location:
  • Phone: 386-684-0195
  • Fax:
Mailing address:
  • Phone: 386-684-0195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP-APRN11000137
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP-APRN11000137
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: