Provider Demographics
NPI:1982461315
Name:SULLIVAN, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:INKLOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4195 GUN CLUB RD
Mailing Address - Street 2:
Mailing Address - City:MURRYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15668-9103
Mailing Address - Country:US
Mailing Address - Phone:724-316-2197
Mailing Address - Fax:
Practice Address - Street 1:4195 GUN CLUB RD
Practice Address - Street 2:
Practice Address - City:MURRYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15668-9103
Practice Address - Country:US
Practice Address - Phone:724-316-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004504225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant