Provider Demographics
NPI:1649739293
Name:MAYES-SULLIVAN, BRENDA LOUISE
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LOUISE
Last Name:MAYES-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 1:2255 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5417
Mailing Address - Country:US
Mailing Address - Phone:810-732-8087
Mailing Address - Fax:
Practice Address - Street 1:2255 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5417
Practice Address - Country:US
Practice Address - Phone:810-732-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703064196164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse