Provider Demographics
NPI:1790486058
Name:BUSTAMANTE, VALERIE J
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:J
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 1:8715 LINDHOLM DR APT 2D
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-1882
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13825 HUNTON LN # 6190
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6190
Practice Address - Country:US
Practice Address - Phone:704-897-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7518225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant