Provider Demographics
NPI:1922574920
Name:SULLIVAN, SHANNON (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 E EATON AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3100
Mailing Address - Country:US
Mailing Address - Phone:209-553-0737
Mailing Address - Fax:
Practice Address - Street 1:20 E EATON AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3100
Practice Address - Country:US
Practice Address - Phone:209-553-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP0016X
IA789456163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA699004OtherBOVNPT
CA$$$$$$$$$OtherSOCIAL SECURITY