Provider Demographics
NPI:1902566920
Name:SULLIVAN, LORI (APRN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 TREEMONT AVE SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-3535
Mailing Address - Country:US
Mailing Address - Phone:386-871-1726
Mailing Address - Fax:
Practice Address - Street 1:458 TREEMONT AVE SW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32908-3535
Practice Address - Country:US
Practice Address - Phone:386-871-1726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF09210413363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily