Provider Demographics
NPI:1457358079
Name:SULLIVAN, LAURA A (CRNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 STILL WATER DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-8314
Mailing Address - Country:US
Mailing Address - Phone:334-434-2417
Mailing Address - Fax:334-503-7869
Practice Address - Street 1:DEPT OF VET AFFAIRS WIREGRASS HBPC
Practice Address - Street 2:301 ANDREWS AVENUE
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-272-4670
Practice Address - Fax:334-503-7869
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-093306363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALQ37338Medicare UPIN