=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134058365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORRY LYN SULLIVAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2026
-----------------------------------------------------
Last Update Date | 05/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11602 LAKE UNDERHILL RD STE 129
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-4460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-277-5400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10913 MOSS PARK RD UNIT 935
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-6062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-398-4206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | SI7028
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------