Provider Demographics
NPI:1316905938
Name:SULLIVAN, COLLEEN P (MSN CS C AP MHCNS AP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSN CS C AP MHCNS AP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:PATRICIA
Other - Last Name:SULLIVAN-RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CS CA P MHCNS CS A
Mailing Address - Street 1:329 NW ROCKHILL LN
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081
Mailing Address - Country:US
Mailing Address - Phone:816-525-9787
Mailing Address - Fax:816-525-1191
Practice Address - Street 1:10918 ELM AVENUE
Practice Address - Street 2:CRITTENTON CHILDRENS CENTER
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134
Practice Address - Country:US
Practice Address - Phone:816-765-6600
Practice Address - Fax:816-767-4159
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1405842052363LP0808X
MO097147363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health