Provider Demographics
NPI:1720056963
Name:SUNDSTROM, LAURA (CNM)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SUNDSTROM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-5910
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CENTER
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000279367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid