Provider Demographics
NPI:1558185918
Name:SULLINS, LAVERN JENNIE (LMT, MLD-C)
Entity type:Individual
Prefix:MRS
First Name:LAVERN
Middle Name:JENNIE
Last Name:SULLINS
Suffix:
Gender:F
Credentials:LMT, MLD-C
Other - Prefix:MRS
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:SULLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT, MLD-C
Mailing Address - Street 1:17397 E 520 RD
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-5159
Mailing Address - Country:US
Mailing Address - Phone:316-833-3505
Mailing Address - Fax:
Practice Address - Street 1:8514 N 128TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6242
Practice Address - Country:US
Practice Address - Phone:316-833-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK157239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist