1407121221 NPI number — MRS. AMANDA MARIE SULLIVAN L.P.N,

Table of content: MRS. AMANDA MARIE SULLIVAN L.P.N, (NPI 1407121221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407121221 NPI number — MRS. AMANDA MARIE SULLIVAN L.P.N,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
AMANDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.P.N,
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTSON
Provider Other First Name:
AMANDA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407121221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALL RIVER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53932-9570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-382-5666
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL RIVER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53932-9570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-382-5666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  304840-31 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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