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:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ARROWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1869
Mailing Address - Country:US
Mailing Address - Phone:607-266-7800
Mailing Address - Fax:607-216-0093
Practice Address - Street 1:20 ARROWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-266-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05330983Medicaid