Healthcare Provider Details

I. General information

NPI: 1619707932
Provider Name (Legal Business Name): CONNOR SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 O ST
LINCOLN NE
68510-1125
US

IV. Provider business mailing address

2444 O ST
LINCOLN NE
68510-1125
US

V. Phone/Fax

Practice location:
  • Phone: 402-475-7666
  • Fax: 402-476-9623
Mailing address:
  • Phone: 402-475-7666
  • Fax: 402-476-9623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3445
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: