Provider Demographics
NPI:1558762476
Name:LAUREYS, KENLYN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KENLYN
Middle Name:MARIE
Last Name:LAUREYS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KENLYN
Other - Middle Name:MARIE
Other - Last Name:FARLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:100 E WAYNE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2394
Mailing Address - Country:US
Mailing Address - Phone:574-334-5400
Mailing Address - Fax:
Practice Address - Street 1:3900 HOLLYWOOD RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9149
Practice Address - Country:US
Practice Address - Phone:269-428-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009215A363LF0000X
MI4704266783363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71009215AOtherSTATE LICENSE