Provider Demographics
NPI:1477857761
Name:SULLIVAN, DANA (LMP)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SUPERMALL WAY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-6511
Mailing Address - Country:US
Mailing Address - Phone:253-333-7771
Mailing Address - Fax:
Practice Address - Street 1:1101 SUPERMALL WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-6511
Practice Address - Country:US
Practice Address - Phone:253-333-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019608225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist