Provider Demographics
NPI:1093163404
Name:SULLIVAN, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6866 JACK LONDON DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-4755
Mailing Address - Country:US
Mailing Address - Phone:641-832-8690
Mailing Address - Fax:
Practice Address - Street 1:6866 JACK LONDON DR
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-4755
Practice Address - Country:US
Practice Address - Phone:641-832-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074902225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant