Individual
BERTHA SIEDAH SULLIVN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RN
Contact information
Practice address
635 HAMPTON WAY APT C, JACKSON, MS 39211-2300
(662) 466-2208
Mailing address
635 HAMPTON WAY, JACKSON, MS 39211-2300
(662) 466-2208
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
141-222
AL
163W00000X
Registered Nurse
Primary
895742
MS
163WM0705X
Medical-Surgical Registered Nurse
895742
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
895742
MS BOARD OF NURSING
MS
Enumeration date
01/22/2020
Last updated
01/22/2020
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