Provider Demographics
NPI:1508006149
Name:SULLIVAN, KATHY REBECCA (IDC)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:REBECCA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSRON FIVE MEDICAL DEPARTMENT
Mailing Address - Street 2:NOLF IB BUILDING 169
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MSRON FIVE MEDICAL DEPARTMENT
Practice Address - Street 2:NOLF IB BUILDING 169
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135
Practice Address - Country:US
Practice Address - Phone:619-437-9382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman