Healthcare Provider Details

I. General information

NPI: 1275910366
Provider Name (Legal Business Name): BONNIE RAE SULLIVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 501-951-2775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019020168
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number2019020168
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: