Provider Demographics
NPI:1720533052
Name:BUSTAMANTE, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 W 9TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7259
Mailing Address - Country:US
Mailing Address - Phone:786-376-3964
Mailing Address - Fax:
Practice Address - Street 1:3986 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7000
Practice Address - Country:US
Practice Address - Phone:305-823-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF0816074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily