Individual
MS. MIYA VENETIA SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS, ATC
Contact information
Practice address
3672 W PINE MALL BLVD, ATHLETICS, SAINT LOUIS, MO 63108-3304
(314) 977-7024
Mailing address
19 SOMERSET TERRACE CT, SAINT LOUIS, MO 63136-2406
(314) 521-5084
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2000170998
MO
Other
Enumeration date
05/21/2007
Last updated
07/08/2007
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