Provider Demographics
NPI:1740650167
Name:SULLIVAN, MICHAEL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W GRACE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4911
Mailing Address - Country:US
Mailing Address - Phone:804-783-2505
Mailing Address - Fax:
Practice Address - Street 1:517 W GRACE ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4911
Practice Address - Country:US
Practice Address - Phone:804-783-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172854363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health