Provider Demographics
NPI:1124624671
Name:SULLIVAN, SAVANNAH MAE (PA-C)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:MAE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 S VALENTINA BAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3394
Mailing Address - Country:US
Mailing Address - Phone:937-360-7940
Mailing Address - Fax:
Practice Address - Street 1:333 SKOKIE BLVD STE 108-109
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1613
Practice Address - Country:US
Practice Address - Phone:847-450-6393
Practice Address - Fax:847-919-8375
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007504RX363A00000X
IL085.008952363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program