Provider Demographics
NPI:1033766415
Name:SULLIVAN, AMANDA ANNE
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 S 65TH ST APT 104
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4987
Mailing Address - Country:US
Mailing Address - Phone:708-369-9081
Mailing Address - Fax:
Practice Address - Street 1:801 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7816
Practice Address - Country:US
Practice Address - Phone:262-899-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19520-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist