Individual
CLEMENCE MARIE SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
5100 GAMBLE DR STE 100, MAIL STOP 31200A, SAINT LOUIS PARK, MN 55416-1582
(952) 541-2500
(952) 595-6455
Mailing address
PO BOX 1309 - 8170 33RD AVE S, MS 21110Q, MINNEAPOLIS, MN 55425-4516
(952) 541-2500
(952) 595-6455
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
58690
MN
208000000X
Pediatrics Physician
58690
MN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/10/2010
Last updated
11/18/2014
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