Provider Demographics
NPI:1336267699
Name:SULLIVAN, PAMELA SUE (GNP)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:40055 BOB HOPE DR STE B
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3940
Practice Address - Country:US
Practice Address - Phone:760-202-3946
Practice Address - Fax:760-770-4392
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262478163WG0600X
CA12764363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1409819OtherCIGNA
CA4984336OtherAETNA