Provider Demographics
NPI:1184267171
Name:BASSETT, NICOLE ANDREA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANDREA
Last Name:BASSETT
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 1:42 AVENIDA ALEGRE
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9538
Mailing Address - Country:US
Mailing Address - Phone:505-917-8142
Mailing Address - Fax:
Practice Address - Street 1:236 DON PASQUAL RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-6223
Practice Address - Fax:505-866-2159
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM53892163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool