Provider Demographics
NPI:1730076472
Name:SULLIVAN, LAUREN SUZANNE
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:SUZANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 MASSEE CIR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-4159
Mailing Address - Country:US
Mailing Address - Phone:601-278-3208
Mailing Address - Fax:
Practice Address - Street 1:117 GARLAND HALL
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:601-278-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-23
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program