Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LP0200X | Nurse Practitioner - Pediatrics | 691809 | TX |
Y | 363LP2300X | Nurse Practitioner - Primary Care | AP123430 | TX |
NPI | 1043654577 |
---|---|
Provider Name | Rebecca Jeanne Sullivan |
First Address | Fort Worth, TX 76199-0213 |
Second Address | Fort Worth, TX 76104-2717 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2013 |
Last Update Date | 13/04/2021 |