Provider Demographics
NPI:1720386931
Name:BUSTAMANTE, SHARLA DARLENE (IDC)
Entity Type:Individual
Prefix:
First Name:SHARLA
Middle Name:DARLENE
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS THEODORE ROOSEVELT
Mailing Address - Street 2:CVN 71
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09599-2871
Mailing Address - Country:US
Mailing Address - Phone:757-534-1190
Mailing Address - Fax:
Practice Address - Street 1:USS THEODORE ROOSEVELT
Practice Address - Street 2:CVN 71
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09599-2871
Practice Address - Country:US
Practice Address - Phone:757-534-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman