Provider Demographics
NPI:1114517992
Name:OSULLIVAN, JOANNA DACE (CNIM)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:DACE
Last Name:OSULLIVAN
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 CHEYENNE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-2226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 S WEBER ST STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1928
Practice Address - Country:US
Practice Address - Phone:866-226-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist