Provider Demographics
NPI:1225224983
Name:SULLIVAN, DIANE JARRELS (PTA)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:JARRELS
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-0128
Mailing Address - Country:US
Mailing Address - Phone:804-435-3435
Mailing Address - Fax:804-435-3682
Practice Address - Street 1:500 IRVINGTON ROAD
Practice Address - Street 2:
Practice Address - City:KILMARNOCK,
Practice Address - State:VA
Practice Address - Zip Code:22482
Practice Address - Country:US
Practice Address - Phone:804-435-3435
Practice Address - Fax:804-435-3682
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000138247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194072OtherBC PROVIDER ID
VAC06278OtherMEDICARE
VA20091OtherSENTURA