Individual
IVELISSE SULLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
19 TACOMA STREET, WORCESTER, MA 01605-2010
(508) 852-1805
Mailing address
19 TACOMA ST, WORCESTER, MA 01605-3516
(508) 852-1805
Taxonomy
Speciality
Code
Description
License number
State
374700000X
Technician
Primary
—
—
Other
Enumeration date
09/20/2012
Last updated
10/02/2012
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