Provider Demographics
NPI:1518378967
Name:SULLIVAN, ELIZABETH ANNE
Entity Type:Individual
Prefix:MR
First Name:ELIZABETH
Middle Name:ANNE
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 1:615 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3907
Mailing Address - Country:US
Mailing Address - Phone:580-775-3083
Mailing Address - Fax:
Practice Address - Street 1:615 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3907
Practice Address - Country:US
Practice Address - Phone:580-775-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNEW390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program