Healthcare Provider Details

I. General information

NPI: 1104367135
Provider Name (Legal Business Name): THERESA DAVIS-BATES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W FOOTHILL BLVD
UPLAND CA
91786-8705
US

IV. Provider business mailing address

12900 PARK PLAZA DR STE 150
CERRITOS CA
90703-9329
US

V. Phone/Fax

Practice location:
  • Phone: 562-367-6151
  • Fax:
Mailing address:
  • Phone: 562-977-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95006327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: