Provider Demographics
NPI:1306482518
Name:BUSTOS, MARY BETH (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16401 PEPPERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:ORLAND HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60487-5648
Mailing Address - Country:US
Mailing Address - Phone:708-522-2372
Mailing Address - Fax:
Practice Address - Street 1:6050 STERLING CREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-7752
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily