Provider Demographics
NPI:1477158905
Name:SULLIVAN, ALICIA KIM (NP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:KIM
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S STATE ROUTE 157 STE 102
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4017
Mailing Address - Country:US
Mailing Address - Phone:618-254-2273
Mailing Address - Fax:618-254-8476
Practice Address - Street 1:441 S STATE ROUTE 157 STE 102
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-4017
Practice Address - Country:US
Practice Address - Phone:618-254-2273
Practice Address - Fax:618-254-8476
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2093022275363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner