Provider Demographics
NPI:1538728621
Name:BASS, TYQUANA T
Entity type:Individual
Prefix:
First Name:TYQUANA
Middle Name:T
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 471452
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33247-1452
Mailing Address - Country:US
Mailing Address - Phone:305-417-1941
Mailing Address - Fax:
Practice Address - Street 1:3820 NW 170TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-4529
Practice Address - Country:US
Practice Address - Phone:305-417-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251J00000X, 251E00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No251J00000XAgenciesNursing Care
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty