Healthcare Provider Details

I. General information

NPI: 1023182789
Provider Name (Legal Business Name): PATRICIA L. SULLIVAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 WILLARD ST
FRONTENAC KS
66763-2120
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-8849
  • Fax: 620-231-8847
Mailing address:
  • Phone: 417-347-6843
  • Fax: 417-347-9397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number45489
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5345489
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: