Provider Demographics
NPI:1083094619
Name:BAUTISTA, ALLAN (LVN)
Entity Type:Individual
Prefix:MR
First Name:ALLAN
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 W COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5508
Mailing Address - Country:US
Mailing Address - Phone:714-609-2150
Mailing Address - Fax:
Practice Address - Street 1:1772 W COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5508
Practice Address - Country:US
Practice Address - Phone:714-609-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 238560164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse