Provider Demographics
NPI:1376216754
Name:BAUTISTA, MA. DE JESUS
Entity Type:Individual
Prefix:
First Name:MA. DE JESUS
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11722 LYNN BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-7203
Mailing Address - Country:US
Mailing Address - Phone:813-484-2314
Mailing Address - Fax:813-433-5163
Practice Address - Street 1:11722 LYNN BROOK CIR
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-7203
Practice Address - Country:US
Practice Address - Phone:813-484-2314
Practice Address - Fax:813-433-5163
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist