Provider Demographics
NPI:1013437086
Name:SULLIVAN, SHARLENE CAMPBELL (FNP)
Entity Type:Individual
Prefix:
First Name:SHARLENE
Middle Name:CAMPBELL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:CAMPBELL
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST STE 355
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:
Practice Address - Street 1:2408 BROADMOOR BLVD STE B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2994
Practice Address - Country:US
Practice Address - Phone:318-807-0525
Practice Address - Fax:318-807-1077
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09503363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2451847Medicaid