Provider Demographics
NPI:1558483867
Name:BAUTISTA, KATHLEEN JO (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:JO
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813-1 CHESAPEAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-9401
Mailing Address - Country:US
Mailing Address - Phone:410-221-2266
Mailing Address - Fax:410-221-2878
Practice Address - Street 1:813-1 CHESAPEAKE DRIVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-9401
Practice Address - Country:US
Practice Address - Phone:410-221-2266
Practice Address - Fax:410-221-2878
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR069915363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD499188OtherVO-MHA
MD609550002Medicaid
MD609550004Medicaid
MD479302100Medicaid
MD609550001Medicaid