Basic Information
| Provider Information | |||||||||
| NPI: | 1316905938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MSN CS C AP MHCNS AP | ||||||||
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| OtherLastName: | SULLIVAN-RUSSO | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | PATRICIA | ||||||||
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| OtherCredential: | CS CA P MHCNS CS A | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 329 NW ROCKHILL LN | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165259787 | ||||||||
| FaxNumber: | 8165251191 | ||||||||
| Practice Location | |||||||||
| Address1: | 10918 ELM AVENUE | ||||||||
| Address2: | CRITTENTON CHILDRENS CENTER | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167656600 | ||||||||
| FaxNumber: | 8167674159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1405842052 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 097147 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.