Provider Demographics
NPI:1063032142
Name:MATHESON SULLIVAN, OLIVIA JOYCE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JOYCE
Last Name:MATHESON SULLIVAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 MACKINAW PL SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4534
Mailing Address - Country:US
Mailing Address - Phone:561-315-6335
Mailing Address - Fax:
Practice Address - Street 1:1700 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4032
Practice Address - Country:US
Practice Address - Phone:404-929-5345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN232689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily