Provider Demographics
NPI:1366852345
Name:SULLIVAN, COURTNEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
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 1:5545 FLAT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HEATH SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29058
Mailing Address - Country:US
Mailing Address - Phone:803-320-4797
Mailing Address - Fax:
Practice Address - Street 1:505 WOODLAND DRIVE
Practice Address - Street 2:
Practice Address - City:KERSHAW
Practice Address - State:SC
Practice Address - Zip Code:29067-1704
Practice Address - Country:US
Practice Address - Phone:803-282-7465
Practice Address - Fax:803-262-0198
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22264363LF0000X
SC100813163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1366852345OtherALL INSURERS
SC1366852345Medicaid