Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 36107599 | IL |
N | 207KA0200X | Allergist | 36107599 | IL |
N | 207RA0201X | Internist - Allergy & Immunology | 36107599 | IL |
N | 2080P0201X | Pediatric Allergist | 36107599 | IL |
NPI | 1386650273 |
---|---|
Provider Name | Dr. Lisa Marie Sullivan |
First Address | Lutz, FL 33558-5343 |
Second Address | Highland Park, IL 60035-4650 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 10/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H79608 | (02) | IL |