Provider Demographics
NPI:1932750874
Name:SULLIVAN, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
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 1:2763 TIARA DR
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-3027
Mailing Address - Country:US
Mailing Address - Phone:314-517-6078
Mailing Address - Fax:314-268-5786
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-268-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF01191637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine