Provider Demographics
NPI:1538948260
Name:SULLIVAN, PAMELA NINOSKA (SA-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:NINOSKA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 DAYTON RD
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3022
Mailing Address - Country:US
Mailing Address - Phone:240-564-3356
Mailing Address - Fax:
Practice Address - Street 1:3570 OLNEY LAYTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20830-7581
Practice Address - Country:US
Practice Address - Phone:301-637-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23-587246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant