Provider Demographics
NPI:1912368192
Name:SULLIVAN, TAYLOR ANNE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 N WOODLAND BLVD
Mailing Address - Street 2:UNIT 8284
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32723-8300
Mailing Address - Country:US
Mailing Address - Phone:386-822-7152
Mailing Address - Fax:386-822-8143
Practice Address - Street 1:421 N WOODLAND BLVD
Practice Address - Street 2:UNIT 8284
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-8300
Practice Address - Country:US
Practice Address - Phone:386-822-7152
Practice Address - Fax:386-822-8143
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 42912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL 4291OtherFLORIDA ATHLETIC TRAINING ASSOCIATION LINCENSURE