Provider Demographics
NPI:1336506914
Name:BAUTISTA, WENA ANGULO (PT)
Entity Type:Individual
Prefix:
First Name:WENA
Middle Name:ANGULO
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 CORONA RD STE 301
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2548
Mailing Address - Country:US
Mailing Address - Phone:573-303-5138
Mailing Address - Fax:
Practice Address - Street 1:2011 CORONA RD STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2548
Practice Address - Country:US
Practice Address - Phone:573-303-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.018885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist