Provider Demographics
NPI:1265433122
Name:SULLIVAN, LAURA D (CRNA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 TALLAWANDA RD
Mailing Address - Street 2:STE. 670
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-1206
Mailing Address - Country:US
Mailing Address - Phone:508-567-1969
Mailing Address - Fax:
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-679-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA256715367500000X
CT001968367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001224301Medicare PIN