Provider Demographics
NPI:1750354304
Name:SULLIVAN, ROSALIE M (FAMILY NURSE PRACTIT)
Entity type:Individual
Prefix:MRS
First Name:ROSALIE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735
Mailing Address - Country:US
Mailing Address - Phone:432-336-2291
Mailing Address - Fax:432-336-3557
Practice Address - Street 1:511 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735
Practice Address - Country:US
Practice Address - Phone:432-336-2291
Practice Address - Fax:432-336-3557
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221622363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0042GWOtherBC BS
TXMS1040815OtherDEA NUMBER
TXTXB123474Medicare PIN