Provider Demographics
NPI:1144764077
Name:BAUTISTA, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 LANGSDORF DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3702
Mailing Address - Country:US
Mailing Address - Phone:714-953-4455
Mailing Address - Fax:
Practice Address - Street 1:680 LANGSDORF DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3702
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program