Provider Demographics
NPI:1619150158
Name:SULLIVAN, STEPHANIE SUE (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5773 GOLDEN EAGLE CIR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-1518
Mailing Address - Country:US
Mailing Address - Phone:561-707-2135
Mailing Address - Fax:561-627-3686
Practice Address - Street 1:5773 GOLDEN EAGLE CIR
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-1518
Practice Address - Country:US
Practice Address - Phone:561-707-2135
Practice Address - Fax:561-627-3686
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN874041164W00000X
FLMA41123225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse