Provider Demographics
NPI:1457787277
Name:SULLIVAN, KYLI QUINN
Entity Type:Individual
Prefix:
First Name:KYLI
Middle Name:QUINN
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 1:469 DOANE WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8345
Mailing Address - Country:US
Mailing Address - Phone:843-478-0030
Mailing Address - Fax:
Practice Address - Street 1:941 HOUSTON NORTHCUTT BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3499
Practice Address - Country:US
Practice Address - Phone:843-852-9939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7616171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor