Healthcare Provider Details

I. General information

NPI: 1619468964
Provider Name (Legal Business Name): MARY ANN RATUITA BAUTISTA RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 U ST
SACRAMENTO CA
95818-1433
US

IV. Provider business mailing address

1234 U ST
SACRAMENTO CA
95818-1433
US

V. Phone/Fax

Practice location:
  • Phone: 916-446-3100
  • Fax: 916-446-3699
Mailing address:
  • Phone: 916-446-3100
  • Fax: 916-446-3699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86033733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: