Provider Demographics
NPI:1083960843
Name:SULLIVAN, LAUREN T (NP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:T
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 WITZEL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8375
Mailing Address - Country:US
Mailing Address - Phone:920-233-1540
Mailing Address - Fax:920-651-6951
Practice Address - Street 1:2400 WITZEL AVE STE A
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-8375
Practice Address - Country:US
Practice Address - Phone:920-233-1540
Practice Address - Fax:920-651-6951
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI154169363L00000X
WI4955-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100025102Medicaid
WI2012010636OtherANCC