Provider Demographics
NPI:1578290862
Name:BAUTISTA, ANGELINE CAMILLE EUGENIO
Entity Type:Individual
Prefix:
First Name:ANGELINE CAMILLE
Middle Name:EUGENIO
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 1:25538 CHISOM LN
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1637
Mailing Address - Country:US
Mailing Address - Phone:661-877-6089
Mailing Address - Fax:
Practice Address - Street 1:25538 CHISOM LN
Practice Address - Street 2:
Practice Address - City:STEVENSON RANCH
Practice Address - State:CA
Practice Address - Zip Code:91381-1637
Practice Address - Country:US
Practice Address - Phone:661-877-6089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT43041390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program