Provider Demographics
NPI:1407121221
Name:SULLIVAN, AMANDA MARIE (LPN,)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPN,
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:MATTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:610 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:53932-9570
Mailing Address - Country:US
Mailing Address - Phone:920-382-5666
Mailing Address - Fax:
Practice Address - Street 1:610 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:WI
Practice Address - Zip Code:53932-9570
Practice Address - Country:US
Practice Address - Phone:920-382-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304840-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse