Provider Demographics
NPI:1730715830
Name:SULLIVAN, KATIE (MD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:9000 W WISCONSIN AVENUE
Mailing Address - Street 2:DIVISION OF PEDIATRIC NEPHROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-337-7140
Mailing Address - Fax:414-337-7145
Practice Address - Street 1:9000 W WISCONSIN AVENUE
Practice Address - Street 2:DIVISION OF PEDIATRIC NEPHROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-337-7140
Practice Address - Fax:414-337-7145
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2023-09-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI821492080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1730715830Medicaid