Provider Demographics
NPI:1073627980
Name:SULLIVAN-LIEBIG, PATRICIA ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:SULLIVAN-LIEBIG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:282 OAK HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1810
Mailing Address - Country:US
Mailing Address - Phone:321-863-6531
Mailing Address - Fax:321-254-6196
Practice Address - Street 1:282 OAK HAVEN DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1810
Practice Address - Country:US
Practice Address - Phone:321-863-6531
Practice Address - Fax:321-254-6196
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1717682367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302046100Medicaid
FLG0636OtherBCBSFL
FL430000819OtherRRMCR
FL302046100Medicaid