Provider Demographics
NPI:1023182789
Name:SULLIVAN, PATRICIA L (APRN)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-6843
Mailing Address - Fax:417-347-9397
Practice Address - Street 1:608 WILLARD ST
Practice Address - Street 2:
Practice Address - City:FRONTENAC
Practice Address - State:KS
Practice Address - Zip Code:66763-2120
Practice Address - Country:US
Practice Address - Phone:620-231-8849
Practice Address - Fax:620-231-8847
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45489363LF0000X
KS5345489363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200000860HMedicaid