MEDICARE: MISS KENDELL ANN SULLIVAN CRNA

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	163W00000X	Registered Nurse	041299781	IL
2	367500000X	Certified Registered Nurse Anesthetist	209003976	IL

General Provider Information

NPI Number	:	1659569622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KENDELL ANN SULLIVAN CRNA

Provider Business Mailing Address
First Line	:	1396 OAK RIDGE CT
Second Line	:
City	:	WILLOW SPRINGS
State	:	IL
Zip	:	60480-1369
Country	:	US
Telephone Number	:	312-865-0337
Fax Number	:

Provider Business Practice Location Address
First Line	:	1396 OAK RIDGE CT
Second Line	:
City	:	WILLOW SPRINGS
State	:	IL
Zip	:	60480-1369
Country	:	US
Telephone Number	:	312-865-0337
Fax Number	:

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

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	04/06/2012

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