MEDICARE: SARA SULLIVAN MS, LAT, ATC

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	2255A2300X	Athletic Trainer	AL2962	FL

General Provider Information

NPI Number	:	1225451347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA SULLIVAN MS, LAT, ATC

Provider Business Mailing Address
First Line	:	2225 NURSERY RD APT 41-203
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764-7656
Country	:	US
Telephone Number	:	727-484-4620
Fax Number	:

Provider Business Practice Location Address
First Line	:	4450 E FLETCHER AVE STE C
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-4907
Country	:	US
Telephone Number	:	813-540-4777
Fax Number	:	813-336-2112

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

Provider Enumeration Date	:	01/24/2014
Last Update Date	:	03/25/2021

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