Healthcare Provider Details

I. General information

NPI: 1538817325
Provider Name (Legal Business Name): KIMBERLY ANN SULLIVAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S GOULD AVE
GOULD AR
71643-5041
US

IV. Provider business mailing address

PO BOX 158
DUMAS AR
71639-0158
US

V. Phone/Fax

Practice location:
  • Phone: 870-382-3080
  • Fax: 870-263-4782
Mailing address:
  • Phone: 870-382-3080
  • Fax: 870-263-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95020227
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number229467
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: