Healthcare Provider Details

I. General information

NPI: 1053574574
Provider Name (Legal Business Name): BAULO IRORERE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BAULO ANSEL RN

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2523 EL PORTAL DR
SAN PABLO CA
94806-3305
US

IV. Provider business mailing address

2523 EL PORTAL DR
SAN PABLO CA
94806-3305
US

V. Phone/Fax

Practice location:
  • Phone: 510-215-3700
  • Fax: 510-215-3770
Mailing address:
  • Phone: 510-215-3700
  • Fax: 510-215-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number280037
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: