Provider Demographics
NPI:1316021009
Name:SULLIVAN, JENNIFER A (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S. TAMIAMI TRAIL
Mailing Address - Street 2:VALVE CLINIC
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3509
Mailing Address - Country:US
Mailing Address - Phone:941-917-6968
Mailing Address - Fax:941-917-5437
Practice Address - Street 1:1700 S. TAMIAMI TRAIL
Practice Address - Street 2:VALVE CLINIC
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-3509
Practice Address - Country:US
Practice Address - Phone:941-917-6968
Practice Address - Fax:941-917-5437
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006344363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ57931Medicare UPIN