Provider Demographics
NPI:1558809855
Name:BUSTAMANTE, ANGIE MARY
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:MARY
Last Name:BUSTAMANTE
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 1:1031 SW 124TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2458
Mailing Address - Country:US
Mailing Address - Phone:786-294-5875
Mailing Address - Fax:
Practice Address - Street 1:1031 SW 124TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2458
Practice Address - Country:US
Practice Address - Phone:786-294-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLRN9551808163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst