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General NPI Number Information
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NPI Number | 1619297694
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Entity Type | Individual
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Provider Name | ANDREA MARIE SULLIVAN ANDREA SULLIVAN
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Gender | Female
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Dates
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Enumeration Date | 06/01/2010
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Last Update Date | 06/01/2010
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Provider Practice Location Address
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Address Line | 2150 SAINT ANTHONY AVE
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City | SAINT PAUL
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State | MN
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Zip | 55104-5029
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Country | US
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Telephone | 651-230-1629
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Fax |
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Provider Business Mailing Address
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Address Line | 232 SNELLING AVE S
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City | SAINT PAUL
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State | MN
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Zip | 55105-1944
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Country | US
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Telephone | 651-230-1629
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 20090000761
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License Number State | MN
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