Healthcare Provider Details

I. General information

NPI: 1639659733
Provider Name (Legal Business Name): KACEY SULLIVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 W 5TH AVE STE 900
SPOKANE WA
99204-2948
US

IV. Provider business mailing address

910 W 5TH AVE STE 900
SPOKANE WA
99204-2948
US

V. Phone/Fax

Practice location:
  • Phone: 509-755-5500
  • Fax: 509-744-1741
Mailing address:
  • Phone: 509-755-5500
  • Fax: 509-744-1741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61190646
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: