Provider Demographics
NPI:1750332474
Name:O'SULLIVAN, KELLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SE FAIRWINDS LOOP
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-8087
Mailing Address - Country:US
Mailing Address - Phone:231-838-2765
Mailing Address - Fax:
Practice Address - Street 1:750 SE FAIRWINDS LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-8087
Practice Address - Country:US
Practice Address - Phone:231-838-2765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60593078207Q00000X
MI4301081068207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN19510003OtherMEDICARE INDIV PTAN
MI5185089Medicaid
MION19510OtherMEDICARE GROUP PTAN
MION19510OtherMEDICARE GROUP PTAN