Healthcare Provider Details

I. General information

NPI: 1649869835
Provider Name (Legal Business Name): LAURA SULLIVAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

IV. Provider business mailing address

24 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

V. Phone/Fax

Practice location:
  • Phone: 508-460-3250
  • Fax: 508-453-8152
Mailing address:
  • Phone: 508-460-3250
  • Fax: 508-453-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2346310
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: