Provider Demographics
NPI:1194560060
Name:BASS, ALEXANDRA NICOLE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
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 1:2428 JENKS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4304
Mailing Address - Country:US
Mailing Address - Phone:850-215-8397
Mailing Address - Fax:
Practice Address - Street 1:2428 JENKS AVE STE B
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4304
Practice Address - Country:US
Practice Address - Phone:850-215-8397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA86700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist