Provider Demographics
NPI:1851888978
Name:SULTON, THELISA Y
Entity type:Individual
Prefix:MRS
First Name:THELISA
Middle Name:Y
Last Name:SULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:THELISA
Other - Middle Name:
Other - Last Name:SULTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MEDICAL ASSISTANT
Mailing Address - Street 1:201 COLUMBIA MALL BLVD STE 189
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7550
Mailing Address - Country:US
Mailing Address - Phone:803-602-5570
Mailing Address - Fax:888-958-0279
Practice Address - Street 1:201 COLUMBIA MALL BLVD STE 189
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-7550
Practice Address - Country:US
Practice Address - Phone:803-602-5570
Practice Address - Fax:888-958-0279
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-14
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2018-46169-45207207KI0005X, 332BC3200X, 156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment