Provider Demographics
NPI:1114324886
Name:SULLIVAN, BRENDA L (APRN)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:CARNICLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 S. SANTA FE AVE
Mailing Address - Street 2:SRCH REVENUE CYCLE MGMT
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401
Mailing Address - Country:US
Mailing Address - Phone:785-452-7269
Mailing Address - Fax:785-452-6008
Practice Address - Street 1:400 S. SANTA FE AVE
Practice Address - Street 2:SRCH REVENUE CYCLE MGMT
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401
Practice Address - Country:US
Practice Address - Phone:785-452-7269
Practice Address - Fax:785-452-6008
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76423363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201109170CMedicaid