Provider Demographics
NPI:1578762944
Name:SULLIVAN, CASEY (NP)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:1100 SOUTHFIELD DR STE 1370
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4300
Mailing Address - Country:US
Mailing Address - Phone:317-837-5566
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:6911 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8926
Practice Address - Country:US
Practice Address - Phone:317-272-8033
Practice Address - Fax:317-272-8044
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2021-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71002030A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200865470Medicaid