Provider Demographics
NPI:1164155297
Name:SULLIVAN, CARRINGTON
Entity Type:Individual
Prefix:
First Name:CARRINGTON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 KATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8810
Mailing Address - Country:US
Mailing Address - Phone:769-243-6141
Mailing Address - Fax:601-510-1665
Practice Address - Street 1:434 KATHERINE DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8810
Practice Address - Country:US
Practice Address - Phone:769-243-6141
Practice Address - Fax:601-510-1665
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily