Provider Demographics
NPI:1326126814
Name:SULLIVAN, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 S MERIDIAN STE 101
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7590
Mailing Address - Country:US
Mailing Address - Phone:253-446-3903
Mailing Address - Fax:253-840-6514
Practice Address - Street 1:1703 S MERIDIAN STE 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7590
Practice Address - Country:US
Practice Address - Phone:253-446-3903
Practice Address - Fax:253-840-6514
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87622207N00000X
WAMD00027715207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology