Provider Demographics
NPI:1164925343
Name:BASTO, LANA MARIE ENRIQUEZ (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:LANA MARIE
Middle Name:ENRIQUEZ
Last Name:BASTO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 FARRAGUT AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2110
Mailing Address - Country:US
Mailing Address - Phone:240-900-3933
Mailing Address - Fax:
Practice Address - Street 1:3720 FARRAGUT AVE STE 103
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2110
Practice Address - Country:US
Practice Address - Phone:240-900-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175605363L00000X
MDAC003089363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDAC003089OtherMARYLAND NP LICENSE