Provider Demographics
NPI:1083639421
Name:SULLIVAN, REBECCA OYLER (CRNA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:OYLER
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-345-7320
Practice Address - Street 1:100 PEYTON WAY
Practice Address - Street 2:STE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8767
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:904-494-6467
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35119163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001713625OtherMSBCBS
WV001706470OtherMSBCBS GROUP
WV8219127Medicare PIN
WV270052997OtherBRICKSTREET
WV9333201Medicare PIN
WV1058929OtherBRICKSTREET
WV$$$$$$$$$00OtherOHIO WORKERS COMP
WV0207026000Medicaid
WV0068692000Medicaid
OH2446982Medicaid