MEDICARE: DEORELLA ANSALE BAUTISTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1619752144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEORELLA ANSALE BAUTISTA

Provider Business Mailing Address
First Line	:	7036 PLEASANT VIEW AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-4520
Country	:	US
Telephone Number	:	725-203-2149
Fax Number	:

Provider Business Practice Location Address
First Line	:	7036 PLEASANT VIEW AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-4520
Country	:	US
Telephone Number	:	725-203-2149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2023
Last Update Date	:	08/31/2023

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Directions to “ DEORELLA ANSALE BAUTISTA ” Practice Location

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