Provider Demographics
NPI:1730775495
Name:SULLIVAN, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 LYDIA AVE N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-7550
Mailing Address - Country:US
Mailing Address - Phone:516-860-7294
Mailing Address - Fax:
Practice Address - Street 1:1750 MCGILCHRIST ST SE STE 130
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1691
Practice Address - Country:US
Practice Address - Phone:971-304-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202007792LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse