Provider Demographics
NPI:1275612244
Name:SULLIVAN, LYNETTE M
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:M
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 1:8 CADILLAC DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5087
Mailing Address - Country:US
Mailing Address - Phone:706-717-0341
Mailing Address - Fax:
Practice Address - Street 1:8 CADILLAC DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5087
Practice Address - Country:US
Practice Address - Phone:706-717-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF1006099363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ73652Medicare UPIN
GA50BBKTVMedicare PIN