Provider Demographics
NPI:1629215009
Name:SULLIVAN, STEPHANIE GRACE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:GRACE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 OAK LAUREL
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6721
Mailing Address - Country:US
Mailing Address - Phone:770-757-0048
Mailing Address - Fax:
Practice Address - Street 1:113 OAK LAUREL
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6721
Practice Address - Country:US
Practice Address - Phone:770-757-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor