1427272749 NPI number — MRS. TAMARA RACHELLE BAVOUSETT RN, C-PNP

Table of content: MRS. TAMARA RACHELLE BAVOUSETT RN, C-PNP (NPI 1427272749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427272749 NPI number — MRS. TAMARA RACHELLE BAVOUSETT RN, C-PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAVOUSETT
Provider First Name:
TAMARA
Provider Middle Name:
RACHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, C-PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAWLIK
Provider Other First Name:
TAMARA
Provider Other Middle Name:
RACHELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DNP, APRN, CPNP-PC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427272749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5113 WAYLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79762-5520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-332-2080
Provider Business Mailing Address Fax Number:
866-298-7237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5113 WAYLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79762-5520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-528-4025
Provider Business Practice Location Address Fax Number:
866-298-7237
Provider Enumeration Date:
04/11/2007

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: 363LP0200X , with the licence number:  657564 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 214730801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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