Individual
KELLY ANN O'SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
750 SE FAIRWINDS LOOP, VANCOUVER, WA 98661-8087
(231) 838-2765
Mailing address
750 SE FAIRWINDS LOOP, VANCOUVER, WA 98661-8087
(231) 838-2765
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
MD60593078
WA
207QG0300X
Geriatric Medicine (Family Medicine) Physician
Primary
4301081068
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5185089
—
MI
01
—
N19510003
MEDICARE INDIV PTAN
MI
01
—
ON19510
MEDICARE GROUP PTAN
MI
Enumeration date
05/15/2006
Last updated
03/17/2018
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