Provider Demographics
NPI:1114706686
Name:BASTIAN, LAURA W
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:W
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 ERKIN SMITH RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-8805
Mailing Address - Country:US
Mailing Address - Phone:252-904-1639
Mailing Address - Fax:
Practice Address - Street 1:4008 CAPITAL DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3123
Practice Address - Country:US
Practice Address - Phone:252-937-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC147408163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse