Provider Demographics
NPI:1417453358
Name:LASTRA, BRETT COLEMAN (RN, BSN)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:COLEMAN
Last Name:LASTRA
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 ALDEN PL
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1622
Mailing Address - Country:US
Mailing Address - Phone:201-697-8716
Mailing Address - Fax:
Practice Address - Street 1:1104 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4800
Practice Address - Country:US
Practice Address - Phone:201-833-2400
Practice Address - Fax:201-837-0193
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY691840163WH0200X, 163W00000X
NJ26NR17447600163WI0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection Control
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse