Provider Demographics
NPI:1851161574
Name:OSULLIVAN, IZADI ADORA
Entity Type:Individual
Prefix:MISS
First Name:IZADI
Middle Name:ADORA
Last Name:OSULLIVAN
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 1:2622 E 126TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1424
Mailing Address - Country:US
Mailing Address - Phone:216-418-4796
Mailing Address - Fax:
Practice Address - Street 1:2622 E 126TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1424
Practice Address - Country:US
Practice Address - Phone:216-418-4796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.184833.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse