Healthcare Provider Details

I. General information

NPI: 1053735639
Provider Name (Legal Business Name): AMY SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 HIGHWAY 5
CABOT AR
72023-7328
US

IV. Provider business mailing address

117 S 2ND ST PO BOX 497
AUGUSTA AR
72006-2309
US

V. Phone/Fax

Practice location:
  • Phone: 501-941-1376
  • Fax: 870-569-3594
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-347-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004030
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: