Provider Demographics
NPI:1114943081
Name:SULLIVAN, PATRICIA (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HOLLISTER DR
Mailing Address - Street 2:STE 112
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5265
Mailing Address - Country:US
Mailing Address - Phone:866-825-3227
Mailing Address - Fax:
Practice Address - Street 1:209 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2235
Practice Address - Country:US
Practice Address - Phone:847-566-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
K11502Medicare ID - Type Unspecified