Provider Demographics
NPI:1710321419
Name:SULLIVAN, RENEE MICHELLE (RNFA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MICHELLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-3935
Mailing Address - Country:US
Mailing Address - Phone:509-586-4880
Mailing Address - Fax:
Practice Address - Street 1:1506 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-3935
Practice Address - Country:US
Practice Address - Phone:509-586-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60069253364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative