Healthcare Provider Details

I. General information

NPI: 1265988513
Provider Name (Legal Business Name): JACKIELYN BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-843 HANAKAHI ST
EWA BEACH HI
96706
US

IV. Provider business mailing address

91-843 HANAKAHI ST
EWA BEACH HI
96706-2861
US

V. Phone/Fax

Practice location:
  • Phone: 808-256-4379
  • Fax:
Mailing address:
  • Phone: 808-256-4379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: