Provider Demographics
NPI:1437545720
Name:SULLIVAN, KEISHA DANIELLE (DO)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:DANIELLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL ST., NW SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19441 GOLF VISTA PLAZA, SUITES 230 & 310
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8272
Practice Address - Country:US
Practice Address - Phone:703-729-3420
Practice Address - Fax:703-729-3420
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.007478207QS1201X
MDH0087581207QS1201X
VA0102205648207QS1201X, 207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437545720Medicaid