Provider Demographics
NPI:1033670344
Name:VINCK, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:VINCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 S VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1398
Mailing Address - Country:US
Mailing Address - Phone:816-442-0520
Mailing Address - Fax:
Practice Address - Street 1:4321 WASHINGTON ST STE 6100
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5901
Practice Address - Country:US
Practice Address - Phone:816-932-3470
Practice Address - Fax:816-932-3437
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019027574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant