Provider Demographics
NPI:1306097316
Name:SULLIVAN, MICHELLE LYNN
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
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 1:601 W RIVERSIDE AVE
Mailing Address - Street 2:140
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0621
Mailing Address - Country:US
Mailing Address - Phone:509-624-2111
Mailing Address - Fax:
Practice Address - Street 1:601 W RIVERSIDE AVE
Practice Address - Street 2:140
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0621
Practice Address - Country:US
Practice Address - Phone:509-624-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00052998183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6028559Medicaid
WA6028559Medicaid