Provider Demographics
NPI:1326501503
Name:SULLIVAN, JENIFER REZENDE (FNP)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:REZENDE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 MOTT STREET
Mailing Address - Street 2:100-110
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4237
Mailing Address - Country:US
Mailing Address - Phone:818-963-5690
Mailing Address - Fax:
Practice Address - Street 1:732 MOTT STREET
Practice Address - Street 2:100-110
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4237
Practice Address - Country:US
Practice Address - Phone:818-963-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011562363LF0000X
CANP95011562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95011562Medicaid