Provider Demographics
NPI:1457072324
Name:SULLIVAN, CASSANDRA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:MICHELLE
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 1:1926 THOMAS LN
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5114
Mailing Address - Country:US
Mailing Address - Phone:706-910-2725
Mailing Address - Fax:
Practice Address - Street 1:1926 THOMAS LANE AUGUSTA, GA
Practice Address - Street 2:
Practice Address - City:AUGSTA
Practice Address - State:GA
Practice Address - Zip Code:30815-3081
Practice Address - Country:US
Practice Address - Phone:706-910-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAADC000309261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care