Healthcare Provider Details

I. General information

NPI: 1386010379
Provider Name (Legal Business Name): AMANDA SULLIVAN CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 RIVER OAKS DR STE 310
FLOWOOD MS
39232-9512
US

IV. Provider business mailing address

1020 RIVER OAKS DR 310
FLOWOOD MS
39232-9512
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-5006
  • Fax: 601-932-5447
Mailing address:
  • Phone: 601-932-5006
  • Fax: 601-932-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR882573
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: