Provider Demographics
NPI:1942517206
Name:GUTIERREZ, MARIA BASILISA (LVN)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:BASILISA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579728
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-9728
Mailing Address - Country:US
Mailing Address - Phone:209-589-5219
Mailing Address - Fax:
Practice Address - Street 1:2213 VERA CRUZ DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2310
Practice Address - Country:US
Practice Address - Phone:209-589-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN219813164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse