MEDICARE: JANE SULLA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704270879	MI

General Provider Information

NPI Number	:	1205062049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE SULLA FNP

Provider Business Mailing Address
First Line	:	1845 MIDCHESTER DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-1138
Country	:	US
Telephone Number	:	248-722-4644
Fax Number	:

Provider Business Practice Location Address
First Line	:	1845 MIDCHESTER DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-1138
Country	:	US
Telephone Number	:	248-722-4644
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	03/18/2015

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