Basic Information
| Provider Information | |||||||||
| NPI: | 1184905283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1278 N LAFAYETTE DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8037744626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1278 N LAFAYETTE DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8037744626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2011 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP4072 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 18516 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP2747 | 05 | SC | MEDICAID |