Provider Demographics
NPI:1710077045
Name:SULLIVAN, JANET LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:LYNN
Other - Last Name:BURKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2000 EOFF ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3823
Mailing Address - Country:US
Mailing Address - Phone:304-234-8663
Mailing Address - Fax:304-234-8960
Practice Address - Street 1:2000 EOFF ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3823
Practice Address - Country:US
Practice Address - Phone:304-234-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34313367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0889696Medicaid
WV0066099000Medicaid
WV0066099000Medicaid