Healthcare Provider Details

I. General information

NPI: 1750919122
Provider Name (Legal Business Name): NICOLE SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 837
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

15 ALPINE CT
LITTLE ROCK AR
72205-4219
US

V. Phone/Fax

Practice location:
  • Phone: 501-526-6020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD.70087066
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.70087066
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: