Provider Demographics
NPI:1013100650
Name:SULLIVAN, CHRISTIE DAWN
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:DAWN
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 1:6831 BUCK LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6327
Mailing Address - Country:US
Mailing Address - Phone:540-786-5902
Mailing Address - Fax:
Practice Address - Street 1:10411 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22553-1798
Practice Address - Country:US
Practice Address - Phone:540-785-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006891225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist