Provider Demographics
NPI:1790086221
Name:SULLIVAN, MELISSA ANNE (FNP)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E GLAUCUS ST APT A
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1603
Mailing Address - Country:US
Mailing Address - Phone:760-846-0151
Mailing Address - Fax:
Practice Address - Street 1:141 E GLAUCUS ST
Practice Address - Street 2:APT A
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1603
Practice Address - Country:US
Practice Address - Phone:760-846-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily