Provider Demographics
NPI:1679995112
Name:SULLIVAN, HAZEL LEANN (AG- ACNP)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:LEANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:AG- ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 LITTLE ROCK DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MS
Mailing Address - Zip Code:39327-9118
Mailing Address - Country:US
Mailing Address - Phone:601-416-7816
Mailing Address - Fax:
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:601-483-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-18
Last Update Date:2014-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854988363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care