Provider Demographics
NPI:1295188498
Name:SULLIVAN, HEIDI (NP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:HASBROUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:836 E. 65TH STREET
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-3555
Practice Address - Street 1:102 BRYAN WOODS ROAD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-1225
Practice Address - Country:US
Practice Address - Phone:912-898-1122
Practice Address - Fax:912-898-9944
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN106514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181045BMedicaid