Provider Demographics
NPI:1932632635
Name:BANUELOS, NANCY (RN)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 CALIFORNIA AVE
Mailing Address - Street 2:400B
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-7081
Mailing Address - Country:US
Mailing Address - Phone:661-459-1900
Mailing Address - Fax:661-459-1974
Practice Address - Street 1:4900 CALIFORNIA AVE
Practice Address - Street 2:400B
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-7024
Practice Address - Country:US
Practice Address - Phone:661-459-1900
Practice Address - Fax:661-459-1974
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA612020261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)