Provider Demographics
NPI:1073393708
Name:BAUTISTA, DIANA VERONICA (FNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:VERONICA
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15977 W WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7756
Mailing Address - Country:US
Mailing Address - Phone:623-533-1063
Mailing Address - Fax:
Practice Address - Street 1:15182 N 75TH AVE STE 180
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4722
Practice Address - Country:US
Practice Address - Phone:602-567-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2023064248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily