Healthcare Provider Details

I. General information

NPI: 1730715830
Provider Name (Legal Business Name): KATIE SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVENUE DIVISION OF PEDIATRIC NEPHROLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVENUE DIVISION OF PEDIATRIC NEPHROLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-337-7140
  • Fax: 414-337-7145
Mailing address:
  • Phone: 414-337-7140
  • Fax: 414-337-7145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number82149
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: