Provider Demographics
NPI:1699008359
Name:SULLIVAN, KIMBERLY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RAWLINS DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-5881
Mailing Address - Country:US
Mailing Address - Phone:302-990-3280
Mailing Address - Fax:302-990-3290
Practice Address - Street 1:100 RAWLINS DR
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-5881
Practice Address - Country:US
Practice Address - Phone:302-990-3280
Practice Address - Fax:302-990-3290
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003687363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical