Provider Demographics
NPI:1649602061
Name:BAST, LORI LYNN (RN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:BAST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:LYNN
Other - Last Name:MCDONAGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5515
Mailing Address - Country:US
Mailing Address - Phone:616-774-8789
Mailing Address - Fax:616-776-1305
Practice Address - Street 1:1450 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5515
Practice Address - Country:US
Practice Address - Phone:616-774-8789
Practice Address - Fax:616-776-1305
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294077163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management