Provider Demographics
NPI:1083601892
Name:SULLIVAN, KRISTINA L (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 AVERY ST STE 501
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5192
Mailing Address - Country:US
Mailing Address - Phone:304-422-3904
Mailing Address - Fax:304-422-3924
Practice Address - Street 1:800 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5340
Practice Address - Country:US
Practice Address - Phone:304-424-2590
Practice Address - Fax:304-422-3924
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV45817367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2441281Medicaid
WV2605395000Medicaid
8232171Medicare ID - Type Unspecified