Provider Demographics
NPI:1780051110
Name:SULLIVAN, BECKY LYNN (PA)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3480 YORKSHIRE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1886
Mailing Address - Country:US
Mailing Address - Phone:859-263-5140
Mailing Address - Fax:859-263-5141
Practice Address - Street 1:3480 YORKSHIRE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1886
Practice Address - Country:US
Practice Address - Phone:859-263-5140
Practice Address - Fax:859-263-5141
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100387430Medicaid