Provider Demographics
NPI:1326418658
Name:SULLIVAN, CARISA R (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CARISA
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 W AMARILLO BLVD BLDG WEST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1990
Mailing Address - Country:US
Mailing Address - Phone:806-355-9703
Mailing Address - Fax:806-468-1500
Practice Address - Street 1:6010 W AMARILLO BLVD BLDG WEST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1990
Practice Address - Country:US
Practice Address - Phone:806-355-9703
Practice Address - Fax:806-468-1500
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200615620 AMedicaid
NM77376714Medicaid
TX352922401Medicaid
TX352922402Medicaid
TX352922401Medicaid