Basic Information
| Provider Information | |||||||||
| NPI: | 1316992290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTLEBERRY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94061 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981249461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253533788 | ||||||||
| FaxNumber: | 4253538041 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S STILLAGUAMISH AVE | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982231642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064352133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00142650 | WA | N | Nursing Service Providers | Registered Nurse | 367500000X | AP30006034 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 9641416 | 05 | WA | MEDICAID |