MEDICARE: MS. MIYA VENETIA SULLIVAN MS, 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	2000170998	MO

General Provider Information

NPI Number	:	1649488503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MIYA VENETIA SULLIVAN MS, ATC

Provider Business Mailing Address
First Line	:	19 SOMERSET TERRACE CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2406
Country	:	US
Telephone Number	:	314-521-5084
Fax Number	:

Provider Business Practice Location Address
First Line	:	3672 W PINE MALL BLVD
Second Line	:	ATHLETICS
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-3304
Country	:	US
Telephone Number	:	314-977-7024
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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