Basic Information
| Provider Information | |||||||||
| NPI: | 1922348002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINZIE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAGEE | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4955 S STATE ROUTE 159 | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | GLEN CARBON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887855 | ||||||||
| FaxNumber: | 6182887866 | ||||||||
| Practice Location | |||||||||
| Address1: | 6812 STATE ROUTE 162 | ||||||||
| Address2: | SUITE 21 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887855 | ||||||||
| FaxNumber: | 6182887866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2013 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-010209 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.