Provider Demographics
NPI:1790311603
Name:SULLIVAN, RACHELL ALISSIA
Entity Type:Individual
Prefix:
First Name:RACHELL
Middle Name:ALISSIA
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 1:3500 OAK LAWN AVE STE 760
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4308
Mailing Address - Country:US
Mailing Address - Phone:972-646-8346
Mailing Address - Fax:
Practice Address - Street 1:3500 OAK LAWN AVE STE 760
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4308
Practice Address - Country:US
Practice Address - Phone:972-646-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145381363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily