Provider Demographics
NPI:1467158105
Name:SULLIVAN, AMBER ANN MARIE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:ANN MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 HUNTER LN
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-7333
Mailing Address - Country:US
Mailing Address - Phone:731-676-1173
Mailing Address - Fax:
Practice Address - Street 1:400 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3120
Practice Address - Country:US
Practice Address - Phone:731-287-2308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN212119163W00000X
TN33135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse