Provider Demographics
NPI:1043654577
Name:SULLIVAN, REBECCA JEANNE (CPNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JEANNE
Other - Last Name:SHERRILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1401 W PULASKI ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2717
Practice Address - Country:US
Practice Address - Phone:682-885-8012
Practice Address - Fax:682-885-8014
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX691809363LP0200X
TXAP123430363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323093001Medicaid