Provider Demographics
NPI:1316365331
Name:SULLIVAN, KRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-549-2229
Mailing Address - Fax:262-549-1657
Practice Address - Street 1:721 AMERICAN AVE STE 304
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-549-2229
Practice Address - Fax:262-549-1657
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65486-20207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology