Provider Demographics
NPI:1396389813
Name:SULLIVAN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
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 1:811 KEYLON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 KEYLON ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2413
Practice Address - Country:US
Practice Address - Phone:931-450-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2660Medicaid