Provider Demographics
NPI:1710538145
Name:BAUTISTA, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
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 1:710 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2119
Mailing Address - Country:US
Mailing Address - Phone:808-536-1015
Mailing Address - Fax:
Practice Address - Street 1:91-1251 RENTON RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1936
Practice Address - Country:US
Practice Address - Phone:808-681-0747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker