Provider Demographics
NPI:1841934775
Name:BUSTILLOS, ANITA MELENDEZ
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:MELENDEZ
Last Name:BUSTILLOS
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 1:258 N THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4311
Mailing Address - Country:US
Mailing Address - Phone:951-743-0396
Mailing Address - Fax:
Practice Address - Street 1:3401 MUSTANG WAY
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9257
Practice Address - Country:US
Practice Address - Phone:951-743-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-ZQJEDF175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist