Provider Demographics
NPI:1780449728
Name:SULLIVAN, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
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 1:3033 SWIGERT RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2107
Mailing Address - Country:US
Mailing Address - Phone:937-267-4407
Mailing Address - Fax:
Practice Address - Street 1:1222 S PATTERSON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2642
Practice Address - Country:US
Practice Address - Phone:937-496-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0035776363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily