MEDICARE: BREANNA KRISTEN SULLIVAN

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	225100000X	Physical Therapist	TTH11237	AL

General Provider Information

NPI Number	:	1598462806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA KRISTEN SULLIVAN

Provider Business Mailing Address
First Line	:	20 ADDISON PARK DR NW APT 206
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35806-2391
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7061 HIGHWAY 72 W STE B
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35806-2959
Country	:	US
Telephone Number	:	256-883-0636
Fax Number	:

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

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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