Healthcare Provider Details

I. General information

NPI: 1952810772
Provider Name (Legal Business Name): DIVINA GRACIA P. BAUTISTA N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIVINA GRACIA R. DELA PENA

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 ADEN ROAD
PASADENA CA
91125
US

IV. Provider business mailing address

1239 ARDEN ROAD
PASADENA CA
91125
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-6393
  • Fax: 626-585-1522
Mailing address:
  • Phone: 626-395-6393
  • Fax: 626-585-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP7363
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License NumberNP7363
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP7363
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: