Provider Demographics
NPI:1497931943
Name:MCKINNIS, LAURA (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MCKINNIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:OKEEFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1505 WISCONSIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-2075
Mailing Address - Country:US
Mailing Address - Phone:262-421-8961
Mailing Address - Fax:
Practice Address - Street 1:1505 WISCONSIN AVE STE 150
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2075
Practice Address - Country:US
Practice Address - Phone:262-421-8961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3279-033364SE0003X
WI3279-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIN/AOtherN/A
WI360599200Medicaid