Provider Demographics
NPI:1528613734
Name:SULLIVAN, COLBY KEITH (ACNP)
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:KEITH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11982
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1982
Mailing Address - Country:US
Mailing Address - Phone:850-479-1805
Mailing Address - Fax:850-479-1829
Practice Address - Street 1:5149 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8756
Practice Address - Country:US
Practice Address - Phone:850-479-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002698363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner