Healthcare Provider Details

I. General information

NPI: 1639009012
Provider Name (Legal Business Name): LAURA MONTOYA QUINCHIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

5506 LINCOLN AVE UNIT 216
MORTON GROVE IL
60053-3433
US

V. Phone/Fax

Practice location:
  • Phone: 309-665-5996
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNA
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: