Healthcare Provider Details

I. General information

NPI: 1275338782
Provider Name (Legal Business Name): AMY LYNN EATON BUSTILLOS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 OLD ANNAPOLIS RD STE A
COLUMBIA MD
21045-2182
US

IV. Provider business mailing address

8990 OLD ANNAPOLIS RD STE A
COLUMBIA MD
21045-2182
US

V. Phone/Fax

Practice location:
  • Phone: 410-531-6006
  • Fax:
Mailing address:
  • Phone: 410-531-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR118549
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR118549
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: