Provider Demographics
NPI:1134584998
Name:SULLIVAN, CLEMENTINE YALONDA
Entity type:Individual
Prefix:
First Name:CLEMENTINE
Middle Name:YALONDA
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 1:151 E METRO DR STE 203
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-4405
Mailing Address - Country:US
Mailing Address - Phone:601-382-8337
Mailing Address - Fax:
Practice Address - Street 1:151 E METRO DR STE 203
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-4405
Practice Address - Country:US
Practice Address - Phone:601-382-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1928225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist