Provider Demographics
NPI:1437499258
Name:SULLIVAN, WENONA
Entity Type:Individual
Prefix:
First Name:WENONA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WINNIE
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:41680 MISS BESSIE DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2906
Mailing Address - Country:US
Mailing Address - Phone:240-256-3711
Mailing Address - Fax:240-256-3612
Practice Address - Street 1:49646 POTOMAC RIVER DR
Practice Address - Street 2:
Practice Address - City:SCOTLAND
Practice Address - State:MD
Practice Address - Zip Code:20687-3124
Practice Address - Country:US
Practice Address - Phone:301-904-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist