Provider Demographics
NPI:1114796075
Name:BASTIAN, LATAYA MONET
Entity Type:Individual
Prefix:
First Name:LATAYA
Middle Name:MONET
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 1:2772 MARENGO ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-6214
Mailing Address - Country:US
Mailing Address - Phone:504-758-8576
Mailing Address - Fax:
Practice Address - Street 1:2772 MARENGO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6214
Practice Address - Country:US
Practice Address - Phone:504-758-8576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA135351376K00000X
ND101435376K00000X
IA342934376K00000X
MECNA97614376K00000X
IDIDLA0040439E376K00000X
MOM0027130202169376K00000X
WANC.61411238376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide