Provider Demographics
NPI:1598031999
Name:SULLIVAN, SUSAN KATHLEEN (MED)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CHURCH CIR STE 312
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1933
Mailing Address - Country:US
Mailing Address - Phone:443-699-0619
Mailing Address - Fax:
Practice Address - Street 1:3123 CATRINA LN
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-4340
Practice Address - Country:US
Practice Address - Phone:443-699-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator