Provider Demographics
NPI:1356584379
Name:SULLIVAN, THEA DELORA (RN)
Entity type:Individual
Prefix:MISS
First Name:THEA
Middle Name:DELORA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 RIVER HEIGHTS XING SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-4870
Mailing Address - Country:US
Mailing Address - Phone:770-272-0716
Mailing Address - Fax:
Practice Address - Street 1:3628 RIVER HEIGHTS XING SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-4870
Practice Address - Country:US
Practice Address - Phone:770-272-0716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN196107163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care