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NPI Code Detail

MEDICARE: ELLEN DAWN SULLIVAN

MEDICARE: ELLEN DAWN 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
1171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1942900063
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLEN DAWN SULLIVAN
Provider Business Mailing Address
First Line : 12320 INTERSTATE 30
Second Line :
City : LITTLE ROCK
State : AR
Zip : 72210-7027
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 12320 INTERSTATE 30
Second Line :
City : LITTLE ROCK
State : AR
Zip : 72210-7027
Country : US
Telephone Number : 501-658-6010
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/07/2023
Last Update Date : 03/07/2023

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Directions to “ ELLEN DAWN SULLIVAN ” Practice Location

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