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General NPI Number Information
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NPI Number | 1124624671
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Entity Type | Individual
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Provider Name | SAVANNAH MAE SULLIVAN PA-C
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Gender | Female
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Dates
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Enumeration Date | 12/09/2020
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Last Update Date | 09/03/2025
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Provider Practice Location Address
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Address Line | 333 SKOKIE BLVD STE 108-109
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City | NORTHBROOK
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State | IL
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Zip | 60062-1613
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Country | US
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Telephone | 847-450-6393
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Fax | 847-919-8375
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Provider Business Mailing Address
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Address Line | 4247 S VALENTINA BAY
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City | SALT LAKE CITY
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State | UT
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Zip | 84107-3394
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Country | US
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Telephone | 937-360-7940
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.007504RX
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085.008952
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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