Provider Demographics
NPI:1851088561
Name:SULLIVAN, CHASITY RENAE (APRN)
Entity Type:Individual
Prefix:
First Name:CHASITY
Middle Name:RENAE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 ROYAL SCOTS WAY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-9332
Mailing Address - Country:US
Mailing Address - Phone:918-577-1003
Mailing Address - Fax:
Practice Address - Street 1:10929 OLD HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-8160
Practice Address - Country:US
Practice Address - Phone:479-250-1562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR223808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine