Provider Demographics
NPI:1922348002
Name:MCKINZIE, LAURA E (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:MCKINZIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:BRAGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4955 S STATE ROUTE 159
Mailing Address - Street 2:UNIT 1
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1907
Mailing Address - Country:US
Mailing Address - Phone:618-288-7855
Mailing Address - Fax:618-288-7866
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:SUITE 21
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8553
Practice Address - Country:US
Practice Address - Phone:618-288-7855
Practice Address - Fax:618-288-7866
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-010209363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner