Provider Demographics
NPI:1104253012
Name:BUNTING, LAURA (RN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BUNTING
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:
Other - Last Name:KAOUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:151 S UNIVERSITY AVE
Mailing Address - Street 2:STE 1610
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4427
Mailing Address - Country:US
Mailing Address - Phone:801-851-7052
Mailing Address - Fax:801-851-7063
Practice Address - Street 1:151 S UNIVERSITY AVE
Practice Address - Street 2:STE 1610
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7052
Practice Address - Fax:801-851-7063
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7672149-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1225109063Medicaid
UT998877660009Medicaid
UTPR00489Medicaid
UT1891865010Medicaid