Provider Demographics
NPI:1538837166
Name:SULLIVAN, AMANDA RENEE (AGACNP)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:RENEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:RENEE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-4050
Mailing Address - Fax:414-805-0855
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-4050
Practice Address - Fax:414-805-0855
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11297363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1538837166Medicaid