Provider Demographics
NPI:1043888456
Name:BUSTOS, KERINA LEE (APRN)
Entity Type:Individual
Prefix:
First Name:KERINA
Middle Name:LEE
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20651 COUNTRY WALK WAY
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-2200
Mailing Address - Country:US
Mailing Address - Phone:505-203-8723
Mailing Address - Fax:
Practice Address - Street 1:12511 WORLD PLAZA LN BLDG 50
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3991
Practice Address - Country:US
Practice Address - Phone:239-343-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-12
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9406123163W00000X
FL11016816367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse