Provider Demographics
NPI:1225354681
Name:SULLIVAN, CLEMENCE MARIE (MD)
Entity type:Individual
Prefix:
First Name:CLEMENCE
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1309 - 8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-541-2500
Mailing Address - Fax:952-595-6455
Practice Address - Street 1:5100 GAMBLE DR STE 100
Practice Address - Street 2:MAIL STOP 31200A
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1582
Practice Address - Country:US
Practice Address - Phone:952-541-2500
Practice Address - Fax:952-595-6455
Is Sole Proprietor?:No
Enumeration Date:2010-04-10
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MN58690207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics