Provider Demographics
NPI:1093034282
Name:SULLIVAN, CYNTHIA EILEEN (APRN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:EILEEN
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-984-1333
Mailing Address - Fax:
Practice Address - Street 1:1220 N HIGHWAY A1A STE 147
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2858
Practice Address - Country:US
Practice Address - Phone:321-984-1333
Practice Address - Fax:321-951-9127
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9435061363L00000X, 364SF0001X
PASP010858363L00000X
PARN511047L363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018876400Medicaid
FLIR690YOtherMEDICARE HF