Provider Demographics
NPI:1215754858
Name:SULLIVAN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:51816 ROAD 426
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:CA
Mailing Address - Zip Code:93644-9734
Mailing Address - Country:US
Mailing Address - Phone:661-204-5072
Mailing Address - Fax:
Practice Address - Street 1:5010 HIGHWAY 140 STE A
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-2434
Practice Address - Country:US
Practice Address - Phone:209-966-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator