Provider Demographics
NPI:1699977900
Name:SULLIVAN, PAIGE NELLEEN
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:NELLEEN
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 1:933 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANDO
Mailing Address - State:ND
Mailing Address - Zip Code:58324-6116
Mailing Address - Country:US
Mailing Address - Phone:701-968-3573
Mailing Address - Fax:
Practice Address - Street 1:933 5TH AVE
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324-6116
Practice Address - Country:US
Practice Address - Phone:701-968-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDSUL732806172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054550Medicare UPIN