Healthcare Provider Details

I. General information

NPI: 1548870405
Provider Name (Legal Business Name): SASHA DANAE SULLARD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 E THORN DR
WICHITA KS
67226-2709
US

IV. Provider business mailing address

2085 S FIELDCREST ST
WICHITA KS
67209-3203
US

V. Phone/Fax

Practice location:
  • Phone: 316-719-3279
  • Fax:
Mailing address:
  • Phone: 316-304-9826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number115734
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: