Provider Demographics
NPI:1104275718
Name:BAUTISTA, JANNETH (NP)
Entity type:Individual
Prefix:
First Name:JANNETH
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 E 1ST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-4086
Mailing Address - Country:US
Mailing Address - Phone:714-556-7246
Mailing Address - Fax:
Practice Address - Street 1:2010 E 1ST ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4086
Practice Address - Country:US
Practice Address - Phone:714-556-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004180363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care