Provider Demographics
NPI:1952810772
Name:BAUTISTA, DIVINA GRACIA P (NP)
Entity Type:Individual
Prefix:
First Name:DIVINA GRACIA
Middle Name:P
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIVINA GRACIA
Other - Middle Name:R
Other - Last Name:DELA PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1239 ARDEN ROAD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91125
Mailing Address - Country:US
Mailing Address - Phone:626-395-6393
Mailing Address - Fax:626-585-1522
Practice Address - Street 1:1239 ADEN ROAD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91125
Practice Address - Country:US
Practice Address - Phone:626-395-6393
Practice Address - Fax:626-585-1522
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7363363LF0000X, 363LS0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool