MEDICARE: NATHALY ANDREA BUSTOS ALFONSO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1972118875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHALY ANDREA BUSTOS ALFONSO

Provider Business Mailing Address
First Line	:	19169 ROMAN WAY
Second Line	:
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20886-5064
Country	:	US
Telephone Number	:	617-803-1485
Fax Number	:

Provider Business Practice Location Address
First Line	:	2921 STRANDEN RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21230-2941
Country	:	US
Telephone Number	:	617-803-1485
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2020
Last Update Date	:	07/13/2022

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