Provider Demographics
NPI:1679919062
Name:CHAMP, LAURIE ELLEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ELLEN
Last Name:CHAMP
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5844 NW BARRY RD
Mailing Address - Street 2:STE. 110
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154-1465
Mailing Address - Country:US
Mailing Address - Phone:816-880-6100
Mailing Address - Fax:816-746-1226
Practice Address - Street 1:5844 NW BARRY RD
Practice Address - Street 2:STE. 110
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1465
Practice Address - Country:US
Practice Address - Phone:816-880-6100
Practice Address - Fax:816-746-1226
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008021543163W00000X
MO2013002281363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1679919062Medicaid
MOH71000019Medicare PIN