Healthcare Provider Details

I. General information

NPI: 1184424152
Provider Name (Legal Business Name): HALEY BROOKE SULLIVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HALEY BROOKE SULLIVAN PA-C

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 11TH ST
PANAMA CITY FL
32401-6304
US

IV. Provider business mailing address

12109 COUNTY ROAD 103
OXFORD FL
34484-2951
US

V. Phone/Fax

Practice location:
  • Phone: 850-785-8557
  • Fax:
Mailing address:
  • Phone: 352-205-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: