Basic Information
| Provider Information | |||||||||
| NPI: | 1336596121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN-EVANS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | COLLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4726 ALCOA HWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377775402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655184589 | ||||||||
| FaxNumber: | 8656812266 | ||||||||
| Practice Location | |||||||||
| Address1: | 1214 TOPSIDE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377775505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659707747 | ||||||||
| FaxNumber: | 8656812222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2016 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN96411 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | APN21230 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.