Healthcare Provider Details

I. General information

NPI: 1255171112
Provider Name (Legal Business Name): LAKEN BUNGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAKEN BUNGO CRNP

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date: 12/15/2025
Reactivation Date: 12/22/2025

III. Provider practice location address

625 RUSTIC LODGE RD
INDIANA PA
15701-3403
US

IV. Provider business mailing address

1011 WATER ST
INDIANA PA
15701-1662
US

V. Phone/Fax

Practice location:
  • Phone: 724-463-3720
  • Fax:
Mailing address:
  • Phone: 724-403-2251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP034738
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN711984
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: