Provider Demographics
NPI:1619297694
Name:SULLIVAN, ANDREA MARIE (ANDREA SULLIVAN)
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ANDREA SULLIVAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 SNELLING AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1944
Mailing Address - Country:US
Mailing Address - Phone:651-230-1629
Mailing Address - Fax:
Practice Address - Street 1:2150 SAINT ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5029
Practice Address - Country:US
Practice Address - Phone:651-230-1629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20090000761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist