Provider Demographics
NPI:1063889509
Name:SULLIVAN, JULIE DIANNE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:DIANNE
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 1:216 LINDA DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4114
Mailing Address - Country:US
Mailing Address - Phone:520-664-5010
Mailing Address - Fax:
Practice Address - Street 1:216 LINDA DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4114
Practice Address - Country:US
Practice Address - Phone:520-664-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical