Provider Demographics
NPI:1841814456
Name:SULLIVAN, TARA ROBERTA (RN,IBCLC,LCCE)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ROBERTA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN,IBCLC,LCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24808 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4411
Mailing Address - Country:US
Mailing Address - Phone:313-618-4206
Mailing Address - Fax:
Practice Address - Street 1:24808 BOSTON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4411
Practice Address - Country:US
Practice Address - Phone:313-618-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-31
Last Update Date:2020-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704245099163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty