Provider Demographics
NPI:1730733080
Name:BASS, SHAKENNA (FNP-C)
Entity type:Individual
Prefix:
First Name:SHAKENNA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E GREEN DR
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27260-6700
Mailing Address - Country:US
Mailing Address - Phone:336-641-7688
Mailing Address - Fax:
Practice Address - Street 1:501 E GREEN DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27260-6700
Practice Address - Country:US
Practice Address - Phone:336-641-7688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012047363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner