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General NPI Number Information
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NPI Number | 1851088561
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Entity Type | Individual
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Provider Name | CHASITY RENAE SULLIVAN APRN
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Gender | Female
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Dates
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Enumeration Date | 04/21/2023
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Last Update Date | 04/21/2023
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Provider Practice Location Address
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Address Line | 10929 OLD HIGHWAY 71
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City | FORT SMITH
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State | AR
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Zip | 72916-8160
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Country | US
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Telephone | 479-250-1562
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Fax |
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Provider Business Mailing Address
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Address Line | 3524 ROYAL SCOTS WAY
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City | FORT SMITH
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State | AR
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Zip | 72908-9332
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Country | US
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Telephone | 918-577-1003
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 223808
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License Number State | AR
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