Healthcare Provider Details

I. General information

NPI: 1295188498
Provider Name (Legal Business Name): HEIDI SULLIVAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI HASBROUCK NP

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 BRYAN WOODS ROAD
SAVANNAH GA
31410-1225
US

IV. Provider business mailing address

836 E. 65TH STREET SUITE 20
SAVANNAH GA
31405
US

V. Phone/Fax

Practice location:
  • Phone: 912-898-1122
  • Fax: 912-898-9944
Mailing address:
  • Phone: 912-819-7878
  • Fax: 912-819-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN106514
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: