Provider Demographics
NPI:1336556190
Name:BASS, SHANNON R (CPD)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:R
Last Name:BASS
Suffix:
Gender:F
Credentials:CPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ROCK POINTE LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-2475
Mailing Address - Country:US
Mailing Address - Phone:919-604-3962
Mailing Address - Fax:
Practice Address - Street 1:113 ROCK POINTE LN
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-2475
Practice Address - Country:US
Practice Address - Phone:919-604-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16637779174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator