MEDICARE: CHRISTINA M SULLIVAN LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LPN.173471.MEDS-IV	OH

General Provider Information

NPI Number	:	1043947799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA M SULLIVAN LPN

Provider Business Mailing Address
First Line	:	1829 KING AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420-2446
Country	:	US
Telephone Number	:	937-503-5923
Fax Number	:

Provider Business Practice Location Address
First Line	:	1829 KING AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420-2446
Country	:	US
Telephone Number	:	937-503-5923
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2022
Last Update Date	:	08/03/2022

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