Provider Demographics
NPI:1578900056
Name:SULLIVAN, AMANDA MICHELLE (ARNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # STREET2
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-0982
Practice Address - Fax:502-588-0987
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9353428363LN0000X
KY3018470363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135006BMedicaid
FL008891500Medicaid
FLHH265ZMedicare PIN