Provider Demographics
NPI:1992163224
Name:DOUMONT, SULLIVAN (PA)
Entity type:Individual
Prefix:MRS
First Name:SULLIVAN
Middle Name:
Last Name:DOUMONT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SULLIVAN
Other - Middle Name:
Other - Last Name:PARKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1196 HITES RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:VA
Mailing Address - Zip Code:22645-2002
Mailing Address - Country:US
Mailing Address - Phone:540-539-2342
Mailing Address - Fax:
Practice Address - Street 1:1830 PLAZA DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6365
Practice Address - Country:US
Practice Address - Phone:540-665-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006194363AM0700X
OK2647363AM0700X
VA0110005994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical