Healthcare Provider Details

I. General information

NPI: 1841506037
Provider Name (Legal Business Name): DENA ISABEL SULLIVAN PTA., ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LAUREL ST
DES MOINES IA
50314-3045
US

IV. Provider business mailing address

309 N ANKENY BLVD SUITE 102
ANKENY IA
50023-1750
US

V. Phone/Fax

Practice location:
  • Phone: 515-323-6485
  • Fax:
Mailing address:
  • Phone: 515-965-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number00988
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number05070219
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: