Provider Demographics
NPI:1396102711
Name:GILLIS, LAURA CHRISTINE (LAC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:GILLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 N MURRAY AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2351
Mailing Address - Country:US
Mailing Address - Phone:414-331-7573
Mailing Address - Fax:
Practice Address - Street 1:4601 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1232
Practice Address - Country:US
Practice Address - Phone:866-855-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-16
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI883-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist