Provider Demographics
NPI:1225306269
Name:SULLIVAN, CAROLYN ANNE (AC PNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:AC PNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-885-0824
Practice Address - Fax:417-890-4174
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209009257363LP0222X
MO2015003901363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1225306269Medicaid
MO1225306269Medicaid