Provider Demographics
NPI:1083027304
Name:SULLIVAN, ANGELA (CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S UNIVERSITY AVE STE 505
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5307
Mailing Address - Country:US
Mailing Address - Phone:501-664-4532
Mailing Address - Fax:501-663-4335
Practice Address - Street 1:500 S UNIVERSITY AVE STE 505
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5307
Practice Address - Country:US
Practice Address - Phone:501-664-4532
Practice Address - Fax:501-663-4335
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL036409163W00000X
ARC003030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208379001Medicaid
AR208379001Medicaid