Healthcare Provider Details

I. General information

NPI: 1144758947
Provider Name (Legal Business Name): LISA RAE BASS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 COURT SQ
ERIN TN
37061-4166
US

IV. Provider business mailing address

60 COURT SQ
ERIN TN
37061-4166
US

V. Phone/Fax

Practice location:
  • Phone: 931-289-3463
  • Fax: 931-289-3499
Mailing address:
  • Phone: 931-289-3463
  • Fax: 931-289-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN60210
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: