Provider Demographics
NPI:1639487952
Name:SULLIVAN, SANDRA EBERLE (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:EBERLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:TARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-0429
Mailing Address - Country:US
Mailing Address - Phone:760-230-5188
Mailing Address - Fax:760-230-5203
Practice Address - Street 1:320 SANTA FE DR
Practice Address - Street 2:SUITE 308
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5138
Practice Address - Country:US
Practice Address - Phone:760-230-5188
Practice Address - Fax:760-230-5203
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP19940363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner