Provider Demographics
NPI:1306004619
Name:BAUTISTA, LUCIE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:LUCIE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RANDALL SQUARE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-331-7178
Mailing Address - Fax:401-331-6181
Practice Address - Street 1:1 RANDALL SQUARE
Practice Address - Street 2:SUITE 205
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-331-7178
Practice Address - Fax:401-331-6181
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMW 110367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife