Individual
STACEY LYNN SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CMA
Contact information
Practice address
1725 W HARRISON ST, SUITE 408, CHICAGO, IL 60612
(312) 997-2229
(312) 666-4163
Mailing address
1646 S 57TH CT, CICERO, IL 60804
(773) 936-8105
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1616020
BC/BS
IL
Enumeration date
11/13/2006
Last updated
07/08/2007
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