Provider Demographics
NPI:1366675563
Name:SULLIVAN, KRISTEN T (PNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:T
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:TOCZYDLOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-2693
Practice Address - Fax:602-933-2697
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN159067163WM0705X
AZAP3435363LP0200X, 363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ471784Medicaid