Provider Demographics
NPI:1689908220
Name:SULLIVAN, WAMAITHA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:WAMAITHA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-379-4864
Mailing Address - Fax:
Practice Address - Street 1:1120 N MELVIN ST
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1477
Practice Address - Country:US
Practice Address - Phone:217-379-4864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000092363LF0000X
IL209007740363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370647938007Medicaid