Provider Demographics
NPI:1194929505
Name:FLOCKENCIER, LAURA L (OD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:FLOCKENCIER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 PASCAL ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2329
Mailing Address - Country:US
Mailing Address - Phone:651-659-0591
Mailing Address - Fax:
Practice Address - Street 1:1540 HUMBOLDT AVE
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3417
Practice Address - Country:US
Practice Address - Phone:651-457-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2487152W00000X
MOT03276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN788214900Medicaid
MN788214900Medicaid