Provider Demographics
NPI:1861468878
Name:BASSELL, MARILYN (CRNA)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BASSELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:VANDERGRIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 47890
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-7890
Mailing Address - Country:US
Mailing Address - Phone:316-685-6112
Mailing Address - Fax:316-652-0340
Practice Address - Street 1:550 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-789-8444
Practice Address - Fax:316-652-0340
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54325367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100301370AMedicaid
KS024200OtherBCBS
KS100301370AMedicaid