Provider Demographics
NPI:1548586548
Name:PENCE, LAURA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:PENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 US HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9609
Mailing Address - Country:US
Mailing Address - Phone:269-781-6600
Mailing Address - Fax:269-781-9228
Practice Address - Street 1:720 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9609
Practice Address - Country:US
Practice Address - Phone:269-781-6600
Practice Address - Fax:269-781-9228
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-058316207Q00000X
MI4301105194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A37669Medicare PIN