Provider Demographics
NPI:1659569622
Name:SULLIVAN, KENDELL ANN (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:KENDELL
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 OAK RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1369
Mailing Address - Country:US
Mailing Address - Phone:312-865-0337
Mailing Address - Fax:
Practice Address - Street 1:1396 OAK RIDGE CT
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60480-1369
Practice Address - Country:US
Practice Address - Phone:312-865-0337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041299781163W00000X
IL209003976367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12709Medicare PIN
IL204062073Medicare Oscar/Certification
IL204061073Medicare Oscar/Certification