Provider Demographics
NPI:1790272466
Name:SULLIVAN, MEGAN ALISE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ALISE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WASHINGTON PARK RD
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-6517
Mailing Address - Country:US
Mailing Address - Phone:339-235-0425
Mailing Address - Fax:
Practice Address - Street 1:8210 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3923
Practice Address - Country:US
Practice Address - Phone:210-450-3134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program