Healthcare Provider Details

I. General information

NPI: 1053735282
Provider Name (Legal Business Name): MARY KATHLEEN SULLIVAN DNP, FNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5659 S REX RD
MEMPHIS TN
38119-3821
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 901-763-3636
  • Fax: 901-763-3694
Mailing address:
  • Phone: 901-226-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN 12894
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12894
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: