1649523515 NPI number — HAYLEY LOIS BUSTOS FNP

Table of content: HAYLEY LOIS BUSTOS FNP (NPI 1649523515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649523515 NPI number — HAYLEY LOIS BUSTOS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSTOS
Provider First Name:
HAYLEY
Provider Middle Name:
LOIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649523515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PORTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46352-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-326-2312
Provider Business Mailing Address Fax Number:
219-326-2584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3777 FRONTAGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-7695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-879-6021
Provider Business Practice Location Address Fax Number:
219-879-6365
Provider Enumeration Date:
10/17/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  28173025A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71004262A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01209920 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 151020011 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201128570 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".