Provider Demographics
NPI:1598641177
Name:MBASSI, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MBASSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURENTINE
Other - Middle Name:
Other - Last Name:MAKENGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:453 ROCKSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:LAVON
Mailing Address - State:TX
Mailing Address - Zip Code:75166-1017
Mailing Address - Country:US
Mailing Address - Phone:817-323-4141
Mailing Address - Fax:
Practice Address - Street 1:453 ROCKSTREAM DR
Practice Address - Street 2:
Practice Address - City:LAVON
Practice Address - State:TX
Practice Address - Zip Code:75166-1017
Practice Address - Country:US
Practice Address - Phone:817-323-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2025041978363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty