Provider Demographics
NPI:1437739778
Name:SULLIVAN, MARLENA (MD)
Entity type:Individual
Prefix:
First Name:MARLENA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-807-1360
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:104 CONTEMPO AVE
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5312
Practice Address - Country:US
Practice Address - Phone:337-807-1360
Practice Address - Fax:337-807-1364
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
LA341165208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program