Provider Demographics
NPI:1437615523
Name:BUSH, LASTACIA (APRN)
Entity Type:Individual
Prefix:
First Name:LASTACIA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LASTACIA
Other - Middle Name:
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7599 W SAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5109
Mailing Address - Country:US
Mailing Address - Phone:407-352-1177
Mailing Address - Fax:
Practice Address - Street 1:7599 W SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5109
Practice Address - Country:US
Practice Address - Phone:407-352-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9374281163WH0200X, 163WP0200X, 163W00000X, 163WR0400X, 163WW0000X, 372600000X, 373H00000X, 374U00000X, 376K00000X
FL11022488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0135291002Medicaid