Healthcare Provider Details

I. General information

NPI: 1447169057
Provider Name (Legal Business Name): ANNALIESA SULLIVAN DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E PINE ST APT 110
PINEDALE WY
82941-5316
US

IV. Provider business mailing address

PO BOX 128
DANIEL WY
83115-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-336-8021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number887
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: