Provider Demographics
NPI:1073820437
Name:SULLIVAN, NINA NOELLA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:NOELLA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6653 JACOB LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-2110
Mailing Address - Country:US
Mailing Address - Phone:541-484-5688
Mailing Address - Fax:
Practice Address - Street 1:2746 SHADOW VIEW DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-4610
Practice Address - Country:US
Practice Address - Phone:541-345-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3320171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO784803OtherASSOCIATED BODYWORK AND MASSAGE PROFESSIONALS