Provider Demographics
NPI:1184183550
Name:SULLIVAN, LISA (ST)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CONSTITUTION CT APT A
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-2150
Mailing Address - Country:US
Mailing Address - Phone:229-364-5501
Mailing Address - Fax:
Practice Address - Street 1:113 CONSTITUTION CT APT A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-2150
Practice Address - Country:US
Practice Address - Phone:229-364-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor