Healthcare Provider Details

I. General information

NPI: 1073430468
Provider Name (Legal Business Name): JUDITH ANN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 CALLE DE LAGO
SOCORRO NM
87801-4805
US

IV. Provider business mailing address

1238 CALLE DE LAGO
SOCORRO NM
87801-4805
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-8991
  • Fax: 575-838-0423
Mailing address:
  • Phone: 575-835-8991
  • Fax: 575-838-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: