Provider Demographics
NPI:1144758947
Name:BASS, LISA RAE (LPN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:BASS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-4166
Mailing Address - Country:US
Mailing Address - Phone:931-289-3463
Mailing Address - Fax:931-289-3499
Practice Address - Street 1:60 COURT SQ
Practice Address - Street 2:
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061-4166
Practice Address - Country:US
Practice Address - Phone:931-289-3463
Practice Address - Fax:931-289-3499
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN60210164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse