KELLEY JOHANNA BASS Physician Assistant License verification

Business Entity

NOT RENEWED

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****63

License Status

NOT RENEWED

Business

First Name

KELLEY

Middle

JOHANNA

Last Name

BASS

Business Name

KELLEY JOHANNA BASS

Original Issue Date

12/20/2005

Effective Date

12/14/2007

Expiration Date

03/01/2010

City

WINFIELD

State

Zip

60190

County

DUPAGE

Ever Disciplined

LastModifiedDate

04/23/2008