Provider Demographics
NPI:1063255164
Name:SULLIVAN, LISA MARIE (APRN-CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 NW 25TH ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4915
Mailing Address - Country:US
Mailing Address - Phone:405-226-0767
Mailing Address - Fax:
Practice Address - Street 1:1491 HEALTH CENTER PKWY
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6492
Practice Address - Country:US
Practice Address - Phone:405-806-2200
Practice Address - Fax:405-806-2207
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK220736363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty