Provider Demographics
NPI:1558692269
Name:SULLIVAN, SHELENTIA
Entity Type:Individual
Prefix:
First Name:SHELENTIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 THOMPSON LN
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3616
Mailing Address - Country:US
Mailing Address - Phone:615-460-4430
Mailing Address - Fax:
Practice Address - Street 1:633 THOMPSON LN
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-3616
Practice Address - Country:US
Practice Address - Phone:615-460-4430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251B00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator