Provider Demographics
NPI:1215287065
Name:BASSETT-JELLEMA, CHRISTINE B (CRNP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:B
Last Name:BASSETT-JELLEMA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:301 ST. PAUL PLACE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 ST. PAUL PLACE
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-332-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR089354363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics