Provider Demographics
NPI:1063976983
Name:BASSETT, COLLIETTA C
Entity type:Individual
Prefix:
First Name:COLLIETTA
Middle Name:C
Last Name:BASSETT
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 1:3730 SAINT PHILIP DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4216
Mailing Address - Country:US
Mailing Address - Phone:901-240-4859
Mailing Address - Fax:
Practice Address - Street 1:2555 CAFFEY ST
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2116
Practice Address - Country:US
Practice Address - Phone:901-351-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25447363LP0808X
WV110891363LP0808X
MS903239363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health