Healthcare Provider Details

I. General information

NPI: 1639142458
Provider Name (Legal Business Name): CYNTHIA ROWLEY-SULLIVAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 18TH AVE
COAL VALLEY IL
61240-9337
US

IV. Provider business mailing address

104 W 18TH AVE
COAL VALLEY IL
61240-9337
US

V. Phone/Fax

Practice location:
  • Phone: 309-799-7518
  • Fax: 309-799-3886
Mailing address:
  • Phone: 309-799-7518
  • Fax: 309-799-3886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: