Provider Demographics
NPI:1841506037
Name:SULLIVAN, DENA ISABEL (PTA, ATC)
Entity type:Individual
Prefix:MRS
First Name:DENA
Middle Name:ISABEL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N ANKENY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-1750
Mailing Address - Country:US
Mailing Address - Phone:515-965-5311
Mailing Address - Fax:
Practice Address - Street 1:450 LAUREL ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3045
Practice Address - Country:US
Practice Address - Phone:515-323-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00988225200000X
NE050702192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer