Provider Demographics
NPI:1114407251
Name:SULLIVAN, ABIGAIL R (DOM)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 AGUA FRIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2577
Mailing Address - Country:US
Mailing Address - Phone:505-303-9696
Mailing Address - Fax:
Practice Address - Street 1:10433 MONTGOMERY PKWY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3831
Practice Address - Country:US
Practice Address - Phone:505-226-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM1230171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty