Basic Information
| Provider Information | |||||||||
| NPI: | 1649495821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173534911 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178848701 | ||||||||
| FaxNumber: | 5178848787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | FL1997192 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0000X | 1997192 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0000X | 4704368871 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
No ID Information.