Provider Demographics
NPI:1679900757
Name:SULLIVAN, SUSAN M (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:O'NEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:621 S NEW BALLAS RD STE 228A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8256
Mailing Address - Country:US
Mailing Address - Phone:314-251-4966
Mailing Address - Fax:314-251-4588
Practice Address - Street 1:621 S NEW BALLAS RD STE 228A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8256
Practice Address - Country:US
Practice Address - Phone:314-251-4966
Practice Address - Fax:314-251-4588
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013039392363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health