Individual
MRS. DIANE JARRELS SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
500 IRVINGTON ROAD, KILMARNOCK,, VA 22482
(804) 435-3435
(804) 435-3682
Mailing address
PO BOX 128, KILMARNOCK, VA 22482-0128
(804) 435-3435
(804) 435-3682
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
2306000138
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
194072
BC PROVIDER ID
VA
01
—
20091
SENTURA
VA
01
—
C06278
MEDICARE
VA
Enumeration date
09/17/2007
Last updated
11/19/2007
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