Provider Demographics
NPI:1447208491
Name:SULLIVAN, AMANDA CLARE (LAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CLARE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BON AIR RD STE 109
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1137
Mailing Address - Country:US
Mailing Address - Phone:415-676-1832
Mailing Address - Fax:
Practice Address - Street 1:5 BON AIR RD STE 109
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1137
Practice Address - Country:US
Practice Address - Phone:415-676-1832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9879171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist