Healthcare Provider Details

I. General information

NPI: 1396796843
Provider Name (Legal Business Name): DONNA J SULLIVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 4TH AVE
GRINNELL IA
50112-1898
US

IV. Provider business mailing address

PO BOX 780
GRINNELL IA
50112-0780
US

V. Phone/Fax

Practice location:
  • Phone: 641-236-2500
  • Fax: 641-236-2539
Mailing address:
  • Phone: 641-236-2500
  • Fax: 641-236-2539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1028
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: