Healthcare Provider Details

I. General information

NPI: 1871412304
Provider Name (Legal Business Name): JOHN MANNING SULLIVAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 APOLLO MANOR CIR APT 103
RIVERVIEW FL
33578-7701
US

IV. Provider business mailing address

10475 APOLLO MANOR CIR APT 103
RIVERVIEW FL
33578-7701
US

V. Phone/Fax

Practice location:
  • Phone: 813-466-9454
  • Fax:
Mailing address:
  • Phone: 813-466-9454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN9264528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: