Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 513943 | CA |
NPI | 1003183146 |
---|---|
Provider Name | Maria Imelda Bautista-Durand |
First Address | Los Angeles, CA 90007-2629 |
Second Address | Los Angeles, CA 90007-2629 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/11/2011 |
Last Update Date | 17/11/2011 |