Provider Demographics
NPI:1568895803
Name:SULLIVAN, JOANN D (PT)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JOANN
Other - Middle Name:D
Other - Last Name:KRACL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4028 OAK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-5783
Mailing Address - Country:US
Mailing Address - Phone:850-625-2393
Mailing Address - Fax:
Practice Address - Street 1:626 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6132
Practice Address - Country:US
Practice Address - Phone:850-871-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23388225100000X
CT009282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist