Healthcare Provider Details

I. General information

NPI: 1689910754
Provider Name (Legal Business Name): DIANA RENEE SULLIVAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 LEESTOWN RD
LEXINGTON KY
40511-1052
US

IV. Provider business mailing address

2250 LEESTOWN RD
LEXINGTON KY
40511-1052
US

V. Phone/Fax

Practice location:
  • Phone: 859-233-4511
  • Fax: 859-281-3928
Mailing address:
  • Phone: 859-233-4511
  • Fax: 859-281-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1120506
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: