Basic Information
| Provider Information | |||||||||
| NPI: | 1679919062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMP | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5844 NW BARRY RD | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641541465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168806100 | ||||||||
| FaxNumber: | 8167461226 | ||||||||
| Practice Location | |||||||||
| Address1: | 5844 NW BARRY RD | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641541465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168806100 | ||||||||
| FaxNumber: | 8167461226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2013 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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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 | 2008021543 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 2013002281 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1679919062 | 05 | MO | MEDICAID |