Provider Demographics
NPI:1619519915
Name:LAURENS, LIECE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LIECE
Middle Name:
Last Name:LAURENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 MILLENNIUM XING
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8877
Mailing Address - Country:US
Mailing Address - Phone:510-926-8033
Mailing Address - Fax:
Practice Address - Street 1:7333 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6280
Practice Address - Country:US
Practice Address - Phone:260-458-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IN10002825A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002825AOtherINDIANA PROFESSIONAL LICENSING AGENCY
1168705OtherNCCPA