Provider Demographics
NPI:1275055980
Name:MUSSELMAN, ANNE LISE SULLIVAN (CNM)
Entity type:Individual
Prefix:
First Name:ANNE LISE
Middle Name:SULLIVAN
Last Name:MUSSELMAN
Suffix:
Gender:
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 GRAPE RD STE B
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3005 GRAPE RD STE B
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2709
Practice Address - Country:US
Practice Address - Phone:800-769-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000480A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05330983Medicaid