KELLEY JOHANNA BASS Physician Assistant License verification

Business Entity

NOT RENEWED

License Type

Physician Assistant

Description

LICENSED PHYSICIAN ASSISTANT

License Number

085002615

License Status

NOT RENEWED

Business

First Name

KELLEY

Middle

JOHANNA

Last Name

BASS

Business Name

KELLEY JOHANNA BASS

Original Issue Date

10/06/2005

Effective Date

12/14/2007

Expiration Date

03/01/2010

City

PLAINFIELD

State

Zip

60585

County

WILL

Ever Disciplined

LastModifiedDate

09/22/2010