Healthcare Provider Details

I. General information

NPI: 1063344422
Provider Name (Legal Business Name): KYLE SULLIVAN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7431 N UNIVERSITY DR STE 200
TAMARAC FL
33321-2956
US

IV. Provider business mailing address

7431 N UNIVERSITY DR STE 200
TAMARAC FL
33321-2956
US

V. Phone/Fax

Practice location:
  • Phone: 954-551-4849
  • Fax:
Mailing address:
  • Phone: 954-551-4849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11047914
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: