Provider Demographics
NPI:1386010379
Name:SULLIVAN, AMANDA (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 RIVER OAKS DR 310
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9512
Mailing Address - Country:US
Mailing Address - Phone:601-932-5006
Mailing Address - Fax:601-932-5447
Practice Address - Street 1:1020 RIVER OAKS DR STE 310
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9512
Practice Address - Country:US
Practice Address - Phone:601-932-5006
Practice Address - Fax:601-932-5447
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882573363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner