Provider Demographics
NPI:1740360353
Name:SULLIVAN, WANDA J (RN)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1839
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1839
Mailing Address - Country:US
Mailing Address - Phone:318-202-5935
Mailing Address - Fax:318-202-5933
Practice Address - Street 1:765 S BONNER ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5801
Practice Address - Country:US
Practice Address - Phone:318-202-5935
Practice Address - Fax:318-202-5933
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN073140363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner