Provider Demographics
NPI:1477938587
Name:SULLIVAN, LARA BETH (CPM)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:BETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 WETTERS RD
Mailing Address - Street 2:
Mailing Address - City:KAWKAWLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48631-9411
Mailing Address - Country:US
Mailing Address - Phone:989-239-6388
Mailing Address - Fax:
Practice Address - Street 1:2424 WETTERS RD
Practice Address - Street 2:
Practice Address - City:KAWKAWLIN
Practice Address - State:MI
Practice Address - Zip Code:48631-9411
Practice Address - Country:US
Practice Address - Phone:989-239-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker