Provider Demographics
NPI:1043992738
Name:SULLIVAN, MARY ELISABETH (STNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISABETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 STALLION DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WAYNOKA
Mailing Address - State:OH
Mailing Address - Zip Code:45171-9814
Mailing Address - Country:US
Mailing Address - Phone:937-779-2182
Mailing Address - Fax:
Practice Address - Street 1:112 STALLION DR
Practice Address - Street 2:
Practice Address - City:LAKE WAYNOKA
Practice Address - State:OH
Practice Address - Zip Code:45171-9814
Practice Address - Country:US
Practice Address - Phone:937-779-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH404196750719376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty