Provider Demographics
NPI:1487850715
Name:BUSTAMANTE, CHECHELLE MARIE TABLANG (FNP)
Entity type:Individual
Prefix:MRS
First Name:CHECHELLE MARIE
Middle Name:TABLANG
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18409 SHADY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-2842
Mailing Address - Country:US
Mailing Address - Phone:301-273-5195
Mailing Address - Fax:
Practice Address - Street 1:18409 SHADY VIEW LN
Practice Address - Street 2:
Practice Address - City:BROOKEVILLE
Practice Address - State:MD
Practice Address - Zip Code:20833-2842
Practice Address - Country:US
Practice Address - Phone:301-273-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-24
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR172810363LP2300X, 163WC0200X
DCRN1003076163WN0800X, 163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Not Answered163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Not Answered163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
Not Answered163WX0106XNursing Service ProvidersRegistered NurseOccupational Health