Provider Demographics
NPI:1700592342
Name:SULLIVAN, JOANNA
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-3432
Mailing Address - Country:US
Mailing Address - Phone:405-712-9172
Mailing Address - Fax:
Practice Address - Street 1:117 ROGERS DR
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848
Practice Address - Country:US
Practice Address - Phone:405-379-6668
Practice Address - Fax:405-379-5372
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171400000XOther Service ProvidersHealth & Wellness Coach