Provider Demographics
NPI:1164155297
Name:SULLIVAN, CARRINGTON
Entity type:Individual
Prefix:
First Name:CARRINGTON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 N STATE ST STE 502
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2414
Mailing Address - Country:US
Mailing Address - Phone:601-944-1781
Mailing Address - Fax:601-353-0439
Practice Address - Street 1:1190 N STATE ST STE 502
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2414
Practice Address - Country:US
Practice Address - Phone:601-944-1781
Practice Address - Fax:601-353-0439
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905405363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily