Provider Demographics
NPI:1649523515
Name:BUSTOS, HAYLEY LOIS (FNP)
Entity type:Individual
Prefix:
First Name:HAYLEY
Middle Name:LOIS
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:FNP
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 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:3777 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7695
Practice Address - Country:US
Practice Address - Phone:219-879-6021
Practice Address - Fax:219-879-6365
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173025A363LF0000X
IN71004262A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01209920OtherRAILROAD MEDICARE PTAN
IN151020011OtherMEDICARE PTAN
IN201128570Medicaid