=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104751981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA SULLIVAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2026
-----------------------------------------------------
Last Update Date | 06/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 397 COPPER HEAD BLF
-----------------------------------------------------
City | WALLING
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38587-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-703-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 397 COPPER HEAD BLF
-----------------------------------------------------
City | WALLING
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38587-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-703-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | 219387
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------