Provider Demographics
NPI:1104030238
Name:SULLIVAN, REGINA ANGELA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:ANGELA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 WHITE CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-1160
Mailing Address - Country:US
Mailing Address - Phone:205-792-3331
Mailing Address - Fax:
Practice Address - Street 1:5530 WHITE CEDAR LN
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-1160
Practice Address - Country:US
Practice Address - Phone:205-792-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3529225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant