Provider Demographics
NPI:1083868863
Name:SULLIVAN, NICHOLAS JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8320 CHAPEL BEND DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8320 CHAPEL BEND DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835
Practice Address - Country:US
Practice Address - Phone:260-438-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002416A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor