Provider Demographics
NPI:1992783328
Name:SULLIVAN, LISA A (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 TREE TOPS DR
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33953-5919
Mailing Address - Country:US
Mailing Address - Phone:603-591-5739
Mailing Address - Fax:
Practice Address - Street 1:8380 RIVERWALK PARK BLVD STE 220
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8758
Practice Address - Country:US
Practice Address - Phone:239-215-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH033956-23-11163W00000X
NH033956-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH000949802Medicare PIN
NHRE6546Medicare PIN