Healthcare Provider Details

I. General information

NPI: 1508303520
Provider Name (Legal Business Name): MARIANNE SULLIVAN L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2017
Last Update Date: 01/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E PATRICK ST
FREDERICK MD
21701-5677
US

IV. Provider business mailing address

11339 BARLEY FIELD WAY
MARRIOTTSVILLE MD
21104-1340
US

V. Phone/Fax

Practice location:
  • Phone: 301-452-3186
  • Fax:
Mailing address:
  • Phone: 301-452-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02392
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: