Provider Demographics
NPI:1184968646
Name:KAVLIE, LAURA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:KAVLIE
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 1:1115 S OAK PARK AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2616
Mailing Address - Country:US
Mailing Address - Phone:616-558-0693
Mailing Address - Fax:
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant