Provider Demographics
NPI:1003640491
Name:BAEZA, KATIE ROSE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ROSE
Last Name:BAEZA
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 1:50 BIRDIE DR
Mailing Address - Street 2:
Mailing Address - City:WHISPERING PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28327-9492
Mailing Address - Country:US
Mailing Address - Phone:414-614-8529
Mailing Address - Fax:
Practice Address - Street 1:50 BIRDIE DR
Practice Address - Street 2:
Practice Address - City:WHISPERING PINES
Practice Address - State:NC
Practice Address - Zip Code:28327-9492
Practice Address - Country:US
Practice Address - Phone:414-614-8529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC372790163W00000X
NC5021273363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse