Healthcare Provider Details

I. General information

NPI: 1992783328
Provider Name (Legal Business Name): LISA A SULLIVAN C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 10/29/2022
Certification Date: 10/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 RIVERWALK PARK BLVD STE 220
FORT MYERS FL
33919-8758
US

IV. Provider business mailing address

4261 TREE TOPS DR
PORT CHARLOTTE FL
33953-5919
US

V. Phone/Fax

Practice location:
  • Phone: 239-215-4104
  • Fax:
Mailing address:
  • Phone: 603-591-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number033956-23-11
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number033956-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: