Provider Demographics
NPI:1225425358
Name:SULLIVAN, ROSE ELIZABETH (CRNA)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:ELIZABETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:2 PROGRESS POINT PKWY
Practice Address - Street 2:DEPT ANESTHESIOLOGY
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2205
Practice Address - Country:US
Practice Address - Phone:800-862-9980
Practice Address - Fax:314-362-1185
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015011476367500000X, 367500000X
MO2010021646163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910022184Medicaid