Provider Demographics
NPI:1548364755
Name:BASS, WALLINE T (NP)
Entity type:Individual
Prefix:
First Name:WALLINE
Middle Name:T
Last Name:BASS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:WALLINE
Other - Middle Name:T
Other - Last Name:DRIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:1525 CLIFTON RD NE
Practice Address - Street 2:SUITE 207
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4200
Practice Address - Country:US
Practice Address - Phone:404-778-4451
Practice Address - Fax:404-778-4355
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP68481Medicare UPIN