Provider Demographics
NPI:1265813315
Name:BACENA-MIANO, CHARISSA GAJETE (MSN, NP-C)
Entity type:Individual
Prefix:MRS
First Name:CHARISSA
Middle Name:GAJETE
Last Name:BACENA-MIANO
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 PHYSICIANS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-1284
Mailing Address - Country:US
Mailing Address - Phone:661-327-0807
Mailing Address - Fax:
Practice Address - Street 1:4000 PHYSICIANS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-1284
Practice Address - Country:US
Practice Address - Phone:661-327-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002396363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner