Provider Demographics
NPI:1437784550
Name:CHANTAL SULLIVAN APRN-BC PLLC
Entity type:Organization
Organization Name:CHANTAL SULLIVAN APRN-BC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHANTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:228-331-3310
Mailing Address - Street 1:928 COURTHOUSE RD UNIT 6
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4110
Mailing Address - Country:US
Mailing Address - Phone:720-271-0941
Mailing Address - Fax:
Practice Address - Street 1:8990 LORRAINE RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4176
Practice Address - Country:US
Practice Address - Phone:228-331-3310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty