Provider Demographics
NPI:1275913832
Name:SULLIVAN, MELISSA LYNN (APRNCNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRNCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-0066
Mailing Address - Fax:
Practice Address - Street 1:1145 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3117
Practice Address - Country:US
Practice Address - Phone:614-293-0066
Practice Address - Fax:614-293-7264
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.17911363LF0000X, 363L00000X
OHRN.363433163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0142822Medicaid