Provider Demographics
NPI:1346894508
Name:SULLIVAN, KAELI
Entity Type:Individual
Prefix:
First Name:KAELI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HILLTOP AVE
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-1462
Mailing Address - Country:US
Mailing Address - Phone:781-558-6411
Mailing Address - Fax:
Practice Address - Street 1:1 HILLTOP AVE
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-1462
Practice Address - Country:US
Practice Address - Phone:781-558-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0127320802OtherTUFTS