Provider Demographics
NPI:1457409807
Name:SULLIVAN, JERRY (CFNP)
Entity type:Individual
Prefix:MS
First Name:JERRY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 186
Mailing Address - Street 2:120 MARKET STREET
Mailing Address - City:WOODLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39776
Mailing Address - Country:US
Mailing Address - Phone:662-456-0111
Mailing Address - Fax:662-456-7335
Practice Address - Street 1:120 MARKET STREET
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:MS
Practice Address - Zip Code:39776
Practice Address - Country:US
Practice Address - Phone:662-456-0111
Practice Address - Fax:662-456-7335
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR739537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0114346Medicaid
MS0114346Medicaid
MSS69279Medicare UPIN