Provider Demographics
NPI:1154930667
Name:BUSTAMANTE, JENNIFER M (MSN, FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 LA PALOMA APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5147
Mailing Address - Country:US
Mailing Address - Phone:310-678-7749
Mailing Address - Fax:
Practice Address - Street 1:15991 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7320
Practice Address - Country:US
Practice Address - Phone:714-852-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013167363LF0000X
CA95077829163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse