Provider Demographics
NPI:1366142135
Name:SULLIVAN, JOANNE MARIE
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:MARIE
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 1:10362 SAINT MATHIAS RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4983
Mailing Address - Country:US
Mailing Address - Phone:651-235-1512
Mailing Address - Fax:
Practice Address - Street 1:10362 SAINT MATHIAS RD
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4983
Practice Address - Country:US
Practice Address - Phone:651-235-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider