Provider Demographics
NPI:1003255761
Name:ALPHONSE SULLIVAN, NATALIE KETSIA (MD)
Entity type:Individual
Prefix:MRS
First Name:NATALIE
Middle Name:KETSIA
Last Name:ALPHONSE SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 KNIGHTS RUN AVE APT 1130
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5943
Mailing Address - Country:US
Mailing Address - Phone:850-559-1100
Mailing Address - Fax:
Practice Address - Street 1:901 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3668
Practice Address - Country:US
Practice Address - Phone:941-485-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
FLME1481332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program