Provider Demographics
NPI:1548444839
Name:SULLIVAN, REBECCA JOY
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:JOY
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 1:1815 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-6653
Mailing Address - Country:US
Mailing Address - Phone:916-492-7420
Mailing Address - Fax:
Practice Address - Street 1:1815 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6653
Practice Address - Country:US
Practice Address - Phone:916-492-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA274421164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
101Y00000XOtherCOUNSELOR