Provider Demographics
NPI:1609525211
Name:BUNCH, SOPHIE LAVONE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:LAVONE
Last Name:BUNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:LAVONE
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1328 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-8441
Mailing Address - Country:US
Mailing Address - Phone:620-755-2088
Mailing Address - Fax:
Practice Address - Street 1:1328 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-8441
Practice Address - Country:US
Practice Address - Phone:620-755-2088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020007954163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse