Provider Demographics
NPI:1487050621
Name:SULLIVAN, NAOMI LEIGH (CNM)
Entity type:Individual
Prefix:MRS
First Name:NAOMI
Middle Name:LEIGH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HEALTH PARK BLVD STE 3002
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3703
Mailing Address - Country:US
Mailing Address - Phone:904-819-1500
Mailing Address - Fax:
Practice Address - Street 1:300 HEALTH PARK BLVD STE 3002
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3703
Practice Address - Country:US
Practice Address - Phone:904-819-1500
Practice Address - Fax:904-810-1023
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172420363LX0001X
FL367A00000X
FL1487050621367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016981400Medicaid
FLIN714ZMedicare PIN