Healthcare Provider Details

I. General information

NPI: 1114913555
Provider Name (Legal Business Name): ANNE LORRAINE SELF SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNE LORRAINE SULLIVAN MD

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 UNION AVE
MEMPHIS TN
38174-0275
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 901-276-2410
  • Fax:
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29526
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD47894
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: