Provider Demographics
NPI:1467847871
Name:SULLIVAN, LAURA MICHELE (MS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-3341
Mailing Address - Country:US
Mailing Address - Phone:828-213-1740
Mailing Address - Fax:
Practice Address - Street 1:11 VANDERBILT PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-1700
Practice Address - Country:US
Practice Address - Phone:828-213-1740
Practice Address - Fax:828-213-1742
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99797363LN0000X
NC5010250363LN0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1467847871Medicaid