Provider Demographics
NPI:1144579418
Name:SULLIVAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 CALIFORNIA CT
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-4098
Mailing Address - Country:US
Mailing Address - Phone:949-697-9228
Mailing Address - Fax:
Practice Address - Street 1:252 CALIFORNIA CT
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-4098
Practice Address - Country:US
Practice Address - Phone:949-697-9228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-02
Last Update Date:2012-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA2143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist