Basic Information
| Provider Information | |||||||||
| NPI: | 1821233552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | MARYLOU | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7350 ROSAS WAY | ||||||||
| Address2: | |||||||||
| City: | CANUTILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 798356104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158774881 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5001 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | 579631 | TX | N | Nursing Service Providers | Registered Nurse | Home Health | 163WP0807X | 579631 | TX | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 163WW0000X | 579631 | TX | Y | Nursing Service Providers | Registered Nurse | Wound Care |
No ID Information.