Provider Demographics
NPI:1831729417
Name:SULLIVN, BERTHA SIEDAH (RN)
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:SIEDAH
Last Name:SULLIVN
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 1:635 HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2300
Mailing Address - Country:US
Mailing Address - Phone:662-466-2208
Mailing Address - Fax:
Practice Address - Street 1:635 HAMPTON WAY APT C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2300
Practice Address - Country:US
Practice Address - Phone:662-466-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL141-222163W00000X
MS895742163WM0705X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS895742OtherMS BOARD OF NURSING