Provider Demographics
NPI:1861714917
Name:SULLIVAN, KANDIS KAY
Entity type:Individual
Prefix:MRS
First Name:KANDIS
Middle Name:KAY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KANDIS
Other - Middle Name:KAY
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1904 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ROTHSCHILD
Mailing Address - State:WI
Mailing Address - Zip Code:54474-1461
Mailing Address - Country:US
Mailing Address - Phone:715-470-0502
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI108168-030163W00000X
WI3857-33363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse