MEDICARE: MRS. LAURA MARIE SULLIVAN RN, CNP

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	363LF0000X	Family Nurse Practitioner	363L00000X	MN
2	363LP2300X	Primary Care Nurse Practitioner	1686	MN

General Provider Information

NPI Number	:	1972819324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA MARIE SULLIVAN RN, CNP

Provider Business Mailing Address
First Line	:	2355 HIGHWAY 36 W STE 400
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-3905
Country	:	US
Telephone Number	:	763-412-1993
Fax Number	:

Provider Business Practice Location Address
First Line	:	2355 HIGHWAY 36 W
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-3902
Country	:	US
Telephone Number	:	763-412-1993
Fax Number	:

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

Provider Enumeration Date	:	08/24/2010
Last Update Date	:	11/12/2020

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