Basic Information
| Provider Information | |||||||||
| NPI: | 1083960843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | 9204567601 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 154169 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 4955 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2012010636 | 01 | WI | ANCC | OTHER | 100025102 | 05 | WI | MEDICAID |