Provider Demographics
NPI:1770917429
Name:BOTELLO, GINA (FNP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BOTELLO
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 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7170
Mailing Address - Country:US
Mailing Address - Phone:928-344-2000
Mailing Address - Fax:928-336-1395
Practice Address - Street 1:2851 S AVENUE B BLDG 19
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7726
Practice Address - Country:US
Practice Address - Phone:928-336-2090
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5180363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ004882Medicaid
AZZ176616OtherMEDICARE PTAN