Provider Demographics
NPI:1003679291
Name:BAUTISTA, MAREYNAL BERNARDO
Entity Type:Individual
Prefix:
First Name:MAREYNAL
Middle Name:BERNARDO
Last Name:BAUTISTA
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 1:18019 CROSSHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18019 CROSSHAVEN DR
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2546
Practice Address - Country:US
Practice Address - Phone:626-641-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF01240217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily