Provider Demographics
NPI:1609898840
Name:SULLIVAN, VICKY LYNN (LPTA)
Entity Type:Individual
Prefix:
First Name:VICKY LYNN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:900 SUNSET DRIVE
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850
Mailing Address - Country:US
Mailing Address - Phone:541-963-1437
Mailing Address - Fax:541-963-1890
Practice Address - Street 1:90 SUNSET DRIVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-963-1437
Practice Address - Fax:541-963-1890
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8027225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant