Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | CNP-01570 | NM |
N | 363LF0000X | Nurse Practitioner - Family Medicine | CNP-01570 | NM |
NPI | 1003180423 |
---|---|
Provider Name | Ms. Audrey Ann Bautista |
First Address | Rio Rancho, NM 87124 |
Second Address | Rio Rancho, NM 87124 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2012 |
Last Update Date | 01/03/2019 |