Provider Demographics
NPI:1043848633
Name:SULLIVAN, MARYBETH (RN)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-235-9600
Mailing Address - Fax:
Practice Address - Street 1:1401 DEKALB ST
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-3405
Practice Address - Country:US
Practice Address - Phone:484-751-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN507395L163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator