Provider Demographics
NPI:1487656278
Name:SULLIVAN, JOAN E (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:E
Other - Last Name:CAMPAGNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4800 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4701
Mailing Address - Country:US
Mailing Address - Phone:602-508-4843
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:95 SOLDIERS PASS RD
Practice Address - Street 2:SUITE A-2
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4781
Practice Address - Country:US
Practice Address - Phone:602-508-4843
Practice Address - Fax:602-508-4830
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN170802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ675919Medicaid