Healthcare Provider Details

I. General information

NPI: 1124957907
Provider Name (Legal Business Name): CHINYERE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 MARIETTA ST NW APT 23
ATLANTA GA
30318-0528
US

IV. Provider business mailing address

159 GRANDIFLORA DR
MCDONOUGH GA
30253-4690
US

V. Phone/Fax

Practice location:
  • Phone: 678-768-0496
  • Fax:
Mailing address:
  • Phone: 833-728-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: