Provider Demographics
NPI:1538125711
Name:SULLIVAN, JANE ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-1610
Mailing Address - Country:US
Mailing Address - Phone:731-772-4199
Mailing Address - Fax:
Practice Address - Street 1:2565 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-1610
Practice Address - Country:US
Practice Address - Phone:731-772-4199
Practice Address - Fax:731-772-7703
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23279363LA2100X, 363LF0000X
TN5597363LA2100X, 363LC0200X
TNAPN5597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007039Medicaid
3904211Medicare ID - Type UnspecifiedTN MEDICARE