Provider Demographics
NPI:1891866646
Name:SULLIVAN, STACEY LYNN (CMA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 S 57TH CT
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804
Mailing Address - Country:US
Mailing Address - Phone:773-936-8105
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 408
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-997-2229
Practice Address - Fax:312-666-4163
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616020OtherBC/BS