Provider Demographics
NPI:1063077352
Name:SULLIVAN, NINA (NP)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8072 PEBBLEPATH PKWY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-7500
Mailing Address - Country:US
Mailing Address - Phone:804-245-2543
Mailing Address - Fax:
Practice Address - Street 1:7240 COURTLAND FARM RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:VA
Practice Address - Zip Code:23069-1564
Practice Address - Country:US
Practice Address - Phone:804-365-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily