Provider Demographics
NPI:1689266439
Name:BAYLESS-BONVENTRE, PETER JOHN (RN)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:BAYLESS-BONVENTRE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41420 STAFFORD CT
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-4020
Mailing Address - Country:US
Mailing Address - Phone:205-234-4723
Mailing Address - Fax:
Practice Address - Street 1:41420 STAFFORD CT
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92203-4020
Practice Address - Country:US
Practice Address - Phone:205-234-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95179121163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-076561OtherRN LICENSURE
CA95179121OtherRN LICENSURE