Provider Demographics
NPI:1568901544
Name:SULLIVAN, STEPHANIE ANN (DNP, CRNA)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 W MADERA CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1445
Mailing Address - Country:US
Mailing Address - Phone:309-360-5827
Mailing Address - Fax:
Practice Address - Street 1:UNITY POINT HEALTH METHODIST
Practice Address - Street 2:221 NE GLEN OAK AVENUE
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-672-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015654367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered