Healthcare Provider Details

I. General information

NPI: 1073627980
Provider Name (Legal Business Name): PATRICIA ANN SULLIVAN-LIEBIG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA ANN SULLIVAN CRNA

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 OAK HAVEN DR
MELBOURNE FL
32940-1810
US

IV. Provider business mailing address

282 OAK HAVEN DR
MELBOURNE FL
32940-1810
US

V. Phone/Fax

Practice location:
  • Phone: 321-863-6531
  • Fax: 321-254-6196
Mailing address:
  • Phone: 321-863-6531
  • Fax: 321-254-6196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP1717682
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: