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General NPI Number Information
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NPI Number | 1033766415
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Entity Type | Individual
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Provider Name | DR. AMANDA ANNE SULLIVAN
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Gender | Female
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Dates
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Enumeration Date | 08/21/2019
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Last Update Date | 08/21/2019
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Provider Practice Location Address
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Address Line | 801 E SUNSET DR
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City | WAUKESHA
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State | WI
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Zip | 53189-7816
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Country | US
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Telephone | 262-899-6010
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Fax |
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Provider Business Mailing Address
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Address Line | 1441 S 65TH ST APT 104
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City | WEST ALLIS
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State | WI
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Zip | 53214-4987
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Country | US
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Telephone | 708-369-9081
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 19520-40
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License Number State | WI
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