Provider Demographics
NPI:1104671007
Name:GLOVER, SULLIVAN THOMAS (RN)
Entity type:Individual
Prefix:
First Name:SULLIVAN
Middle Name:THOMAS
Last Name:GLOVER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2136
Mailing Address - Country:US
Mailing Address - Phone:307-214-3585
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY48989163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse