Provider Demographics
NPI:1306372032
Name:SULTAN, LARISSA S (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:S
Last Name:SULTAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WILLOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6376
Mailing Address - Country:US
Mailing Address - Phone:248-672-0526
Mailing Address - Fax:
Practice Address - Street 1:115 WILLOW LAKE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6376
Practice Address - Country:US
Practice Address - Phone:248-672-0526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276540363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care