Provider Demographics
NPI:1457504433
Name:SULLIVAN, NANCY L (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7007 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2719
Mailing Address - Country:US
Mailing Address - Phone:757-215-2784
Mailing Address - Fax:757-215-2728
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 311
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-947-3170
Practice Address - Fax:757-947-3180
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2014-07-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0024067080363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457504433Medicaid
VA1457504433Medicaid
VAVV0211BMedicare PIN
VAP00914006Medicare PIN