Provider Demographics
NPI:1548654411
Name:PERRIN-SULLIVAN, DONECIA
Entity type:Individual
Prefix:
First Name:DONECIA
Middle Name:
Last Name:PERRIN-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 1:505 PACIFICA DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1757
Mailing Address - Country:US
Mailing Address - Phone:706-373-9184
Mailing Address - Fax:
Practice Address - Street 1:524 SHARTOM DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-4751
Practice Address - Country:US
Practice Address - Phone:706-373-9184
Practice Address - Fax:762-333-8798
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO093014174400000X, 1744P3200X
332B00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No174400000XOther Service ProvidersSpecialist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies