Healthcare Provider Details

I. General information

NPI: 1679103253
Provider Name (Legal Business Name): NELLYN BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CENTRAL AVE NW STE K3
ALBUQUERQUE NM
87105-1647
US

IV. Provider business mailing address

4201 CENTRAL AVE NW STE K3
ALBUQUERQUE NM
87105-1647
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-1739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: