Provider Demographics
NPI:1629659743
Name:SULLIVAN, KAILA RAE (DO)
Entity Type:Individual
Prefix:
First Name:KAILA
Middle Name:RAE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KAILA
Other - Middle Name:RAE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-6460
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:101 MARTIN LUTHER KING JR. DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6460
Practice Address - Country:US
Practice Address - Phone:507-594-6572
Practice Address - Fax:507-594-6959
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31906207Q00000X
390200000X
MN72407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program