Provider Demographics
NPI:1508519935
Name:SULLIVAN, LYNETTA IRENE
Entity type:Individual
Prefix:MS
First Name:LYNETTA
Middle Name:IRENE
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 1:312 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2834
Mailing Address - Country:US
Mailing Address - Phone:575-740-0719
Mailing Address - Fax:
Practice Address - Street 1:312 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2834
Practice Address - Country:US
Practice Address - Phone:575-740-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker