MEDICARE: MRS. JOAN E SULLIVAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN170802	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487656278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOAN E SULLIVAN FNP

Provider Business Mailing Address
First Line	:	4800 N 22ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4701
Country	:	US
Telephone Number	:	602-508-4843
Fax Number	:	602-508-4830

Provider Business Practice Location Address
First Line	:	95 SOLDIERS PASS RD
Second Line	:	SUITE A-2
City	:	SEDONA
State	:	AZ
Zip	:	86336-4781
Country	:	US
Telephone Number	:	602-508-4843
Fax Number	:	602-508-4830

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	03/11/2013

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