Provider Demographics
NPI:1629299219
Name:BANNICK-JUNGE, LAURIE MARIE (MSE)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:MARIE
Last Name:BANNICK-JUNGE
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:MRS
Other - First Name:LAURIE
Other - Middle Name:MARIE
Other - Last Name:JUNGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSE
Mailing Address - Street 1:3137 W. ZACHARY DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4650 W. SWEETWATER AVENUE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ621947Medicaid