MEDICARE: KELLY ANN SULLIVAN D.O.

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	2084P0800X	Psychiatry Physician	0102202783	VA

General Provider Information

NPI Number	:	1407056815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN SULLIVAN D.O.

Provider Business Mailing Address
First Line	:	7447 CENTRAL BUSINESS PARK DR STE 1400
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-2831
Country	:	US
Telephone Number	:	757-756-5600
Fax Number	:	757-904-1602

Provider Business Practice Location Address
First Line	:	7447 CENTRAL BUSINESS PARK DR STE 1400
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-2831
Country	:	US
Telephone Number	:	757-756-5600
Fax Number	:	757-904-1602

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

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	12/12/2019

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