Provider Demographics
NPI:1972307379
Name:SULLIVAN, PAMELA JENIECE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:JENIECE
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 E AMADOR AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3460 WOOLDRIDGE FERRY RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-6131
Practice Address - Country:US
Practice Address - Phone:270-697-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician