Provider Demographics
NPI:1114635414
Name:BUSTAMANTE, ANGELICA M (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:M
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:2625 MCNUTT RD STE B
Practice Address - Street 2:
Practice Address - City:SUNLAND PARK
Practice Address - State:NM
Practice Address - Zip Code:88063-9608
Practice Address - Country:US
Practice Address - Phone:575-589-6540
Practice Address - Fax:575-589-5864
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator