Provider Demographics
NPI:1992292080
Name:SULLIVAN, LAURA ANNE
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANNE
Last Name:SULLIVAN
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 1:5 TERRACE PL
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2427
Mailing Address - Country:US
Mailing Address - Phone:516-639-4795
Mailing Address - Fax:
Practice Address - Street 1:5 TERRACE PL
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2427
Practice Address - Country:US
Practice Address - Phone:516-639-4795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY963619174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist