Healthcare Provider Details

I. General information

NPI: 1790649036
Provider Name (Legal Business Name): OMNI CHERISE SULLIVAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 VICTORS WAY STE 100
ANN ARBOR MI
48108-5217
US

IV. Provider business mailing address

PO BOX 1738
TAYLOR MI
48180-0028
US

V. Phone/Fax

Practice location:
  • Phone: 734-973-0710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704369768
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: