1528464104 NPI number — MRS. ANNA MARIE BAUTISTA AVELLANOSA PT

Table of content: MRS. ANNA MARIE BAUTISTA AVELLANOSA PT (NPI 1528464104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528464104 NPI number — MRS. ANNA MARIE BAUTISTA AVELLANOSA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVELLANOSA
Provider First Name:
ANNA MARIE
Provider Middle Name:
BAUTISTA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1528464104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 BRIARCLIFF RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65616-3735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-339-4069
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 BRANSON LANDING BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-348-8212
Provider Business Practice Location Address Fax Number:
417-348-8218
Provider Enumeration Date:
11/10/2014

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: 225100000X , with the licence number:  PT111250 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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