Healthcare Provider Details

I. General information

NPI: 1356202527
Provider Name (Legal Business Name): MRS. MIYOSHI UMEAKIIRETTA SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8918 BEAU CHASSE DR
SHREVEPORT LA
71115-2774
US

IV. Provider business mailing address

8918 BEAU CHASSE DR
SHREVEPORT LA
71115-2774
US

V. Phone/Fax

Practice location:
  • Phone: 318-458-8025
  • Fax:
Mailing address:
  • Phone: 318-458-8025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number107759
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number107759
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: