Provider Demographics
NPI:1255171112
Name:BUNGO, LAKEN
Entity type:Individual
Prefix:
First Name:LAKEN
Middle Name:
Last Name:BUNGO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LAKEN
Other - Middle Name:
Other - Last Name:BUNGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:153 RAMER FARM LN
Mailing Address - Street 2:
Mailing Address - City:SHELOCTA
Mailing Address - State:PA
Mailing Address - Zip Code:15774-2227
Mailing Address - Country:US
Mailing Address - Phone:724-762-2743
Mailing Address - Fax:
Practice Address - Street 1:9603 HIGHWAY 422 W
Practice Address - Street 2:
Practice Address - City:SHELOCTA
Practice Address - State:PA
Practice Address - Zip Code:15774
Practice Address - Country:US
Practice Address - Phone:724-801-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN711984163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse