MEDICARE: LISA A SULLIVAN C.R.N.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	033956-23-11	NH
2	367500000X	Certified Registered Nurse Anesthetist	033956-23	NH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992783328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A SULLIVAN C.R.N.A.

Provider Business Mailing Address
First Line	:	4261 TREE TOPS DR
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33953-5919
Country	:	US
Telephone Number	:	603-591-5739
Fax Number	:

Provider Business Practice Location Address
First Line	:	8380 RIVERWALK PARK BLVD STE 220
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-8758
Country	:	US
Telephone Number	:	239-215-4104
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	10/29/2022

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