Provider Demographics
NPI:1114151131
Name:SULLIVAN, KIRSTIN KJORDIS (LMT)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:KJORDIS
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 1:7735 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-4003
Mailing Address - Country:US
Mailing Address - Phone:206-910-9778
Mailing Address - Fax:
Practice Address - Street 1:7735 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4003
Practice Address - Country:US
Practice Address - Phone:206-910-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA6007028172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker