Basic Information
| Provider Information | |||||||||
| NPI: | 1093034282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | EILEEN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219841333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 N HIGHWAY A1A STE 147 | ||||||||
| Address2: | |||||||||
| City: | INDIALANTIC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329032858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219841333 | ||||||||
| FaxNumber: | 3219519127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9435061 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 018876400 | 05 | FL | MEDICAID | IR690Y | 01 | FL | MEDICARE HF | OTHER |