Provider Demographics
NPI:1831940634
Name:SULLIVAN, SARA CAMILLE (RN, LMT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:CAMILLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086-3603
Practice Address - Country:US
Practice Address - Phone:501-762-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR88651163W00000X
CARN95310083163W00000X
AR7055225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty