Provider Demographics
NPI:1790652162
Name:BASULTO, ITZIA
Entity type:Individual
Prefix:
First Name:ITZIA
Middle Name:
Last Name:BASULTO
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 1:58457 TWENTYNINE PALMS HIGHWAY
Mailing Address - Street 2:SUITE 102A
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284
Mailing Address - Country:US
Mailing Address - Phone:760-228-9657
Mailing Address - Fax:442-205-0060
Practice Address - Street 1:58457 TWENTYNINE PALMS HIGHWAY
Practice Address - Street 2:SUITE 102A
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:760-228-9657
Practice Address - Fax:442-205-0060
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist