Provider Demographics
NPI:1881916583
Name:SULLIVAN, EMILY BENNETT (PA-C)
Entity type:Individual
Prefix:MS
First Name:EMILY
Middle Name:BENNETT
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 KING ST
Mailing Address - Street 2:APT 2L
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1688
Mailing Address - Country:US
Mailing Address - Phone:336-552-5961
Mailing Address - Fax:
Practice Address - Street 1:1614 NC HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:CREEDMORE
Practice Address - State:NC
Practice Address - Zip Code:27522-1688
Practice Address - Country:US
Practice Address - Phone:336-552-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant