Basic Information
| Provider Information | |||||||||
| NPI: | 1023257086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2156 CHAMBER CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAKE SIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 DIXIE HWY STE N | ||||||||
| Address2: | |||||||||
| City: | FT WRIGHT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410112792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2009 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43346 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100163510 | 05 | KY | MEDICAID |