Provider Demographics
NPI:1316293541
Name:KINNICK, LAURA J (RN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:KINNICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:SUITE 5100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-396-1300
Practice Address - Fax:317-924-8472
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004069A363L00000X
IN28174769A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse