Provider Demographics
NPI:1003590316
Name:SULLIVAN, KERRI JEAN (NP)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 HAWTHORN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-3733
Mailing Address - Country:US
Mailing Address - Phone:774-929-7420
Mailing Address - Fax:
Practice Address - Street 1:516 HAWTHORN ST STE 4
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3733
Practice Address - Country:US
Practice Address - Phone:774-929-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279965363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health