Healthcare Provider Details

I. General information

NPI: 1992541668
Provider Name (Legal Business Name): MIREYA NICHOL BUSTAMANTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 BISCAYNE BLVD
MIAMI FL
33132-1449
US

IV. Provider business mailing address

6721 PIEDRAS BLANCO DR
AUSTIN TX
78747-4084
US

V. Phone/Fax

Practice location:
  • Phone: 877-870-0323
  • Fax: 866-427-3798
Mailing address:
  • Phone: 512-767-4115
  • Fax: 866-427-3798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1000744
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: