Provider Demographics
NPI: | 1487850715 |
---|---|
Name: | BUSTAMANTE, CHECHELLE MARIE TABLANG (RN) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | CHECHELLE MARIE |
Middle Name: | TABLANG |
Last Name: | BUSTAMANTE |
Suffix: | |
Gender: | F |
Credentials: | RN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 18001 WAGONWHEEL CT |
Mailing Address - Street 2: | |
Mailing Address - City: | OLNEY |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 20832-2808 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 301-570-8622 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 18001 WAGONWHEEL CT |
Practice Address - Street 2: | |
Practice Address - City: | OLNEY |
Practice Address - State: | MD |
Practice Address - Zip Code: | 20832-2808 |
Practice Address - Country: | US |
Practice Address - Phone: | 301-570-8622 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-06-24 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
DC | RN1003076 | 163WC0200X, 163WN0800X, 163WX0106X |
MD | R172810 | 163WC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 163WC0200X | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
Not Answered | 163WN0800X | Nursing Service Providers | Registered Nurse | Neuroscience |
Not Answered | 163WX0106X | Nursing Service Providers | Registered Nurse | Occupational Health |