Provider Demographics
NPI:1265581052
Name:SULLIVAN, ANN KATHERINE (OTR-L)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:KATHERINE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TEAL CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5878
Mailing Address - Country:US
Mailing Address - Phone:904-461-0650
Mailing Address - Fax:
Practice Address - Street 1:22 TEAL CIR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-5878
Practice Address - Country:US
Practice Address - Phone:904-461-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 1897225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ0162OtherBC-BS