Healthcare Provider Details

I. General information

NPI: 1841816907
Provider Name (Legal Business Name): EMILY SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 FOXBERRY DR
MEDINA MN
55340-4611
US

IV. Provider business mailing address

4755 FOXBERRY DR
MEDINA MN
55340-4611
US

V. Phone/Fax

Practice location:
  • Phone: 952-807-2519
  • Fax:
Mailing address:
  • Phone: 952-807-2519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number202745
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: