Healthcare Provider Details

I. General information

NPI: 1114560919
Provider Name (Legal Business Name): LAURA SULLIVAN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2019
Last Update Date: 10/17/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8316 TRAFORD LN
WEST SPRINGFIELD VA
22152-1654
US

IV. Provider business mailing address

2642 E SIDE DR
ALEXANDRIA VA
22306-1707
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-8400
  • Fax:
Mailing address:
  • Phone: 571-242-9676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024178355
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: