Provider Demographics
NPI:1912531062
Name:SULLIVAN, LAURA (CRNP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 ROUTE 97 STE 10
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21738-9749
Mailing Address - Country:US
Mailing Address - Phone:410-489-9550
Mailing Address - Fax:410-489-5527
Practice Address - Street 1:2465 ROUTE 97 STE 10
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MD
Practice Address - Zip Code:21738-9749
Practice Address - Country:US
Practice Address - Phone:410-489-9550
Practice Address - Fax:410-489-5527
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR093585363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health