=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790788024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA WHITE BASS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 02/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4005 OLEANDER DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-6816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-790-9949
-----------------------------------------------------
Fax | 910-790-9455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 M AVE UNIT A
-----------------------------------------------------
City | KURE BEACH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28449-3830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-335-5319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | 800112
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------