Provider Demographics
NPI:1700135910
Name:SULLIVAN, NANCY CARLA (LPN)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:CARLA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 DOMANIK DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-2910
Mailing Address - Country:US
Mailing Address - Phone:262-633-4800
Mailing Address - Fax:262-633-5999
Practice Address - Street 1:2000 DOMANIK DR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-2910
Practice Address - Country:US
Practice Address - Phone:262-633-4800
Practice Address - Fax:262-633-5999
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134413164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse