Provider Demographics
NPI:1710238001
Name:SULLIVAN, KAITLIN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 KRESGE WAY
Mailing Address - Street 2:SUITE 30
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4660
Mailing Address - Country:US
Mailing Address - Phone:502-891-8700
Mailing Address - Fax:502-891-8752
Practice Address - Street 1:3900 KRESGE WAY
Practice Address - Street 2:SUITE 30
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4660
Practice Address - Country:US
Practice Address - Phone:502-891-8700
Practice Address - Fax:502-891-8752
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical