Provider Demographics
NPI:1205043015
Name:BAUTISTA, JACQUELINE ANN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:MORALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4423 N NEW ENGLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HARWOOD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60706-4825
Mailing Address - Country:US
Mailing Address - Phone:312-543-3348
Mailing Address - Fax:
Practice Address - Street 1:200 N BERTEAU AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2966
Practice Address - Country:US
Practice Address - Phone:630-833-1400
Practice Address - Fax:630-941-4597
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018206367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered