Provider Demographics
NPI:1386662484
Name:SULLIVAN, MARY A (PCNS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MAUDE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4325
Mailing Address - Country:US
Mailing Address - Phone:401-456-2000
Mailing Address - Fax:401-456-6554
Practice Address - Street 1:50 MAUDE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4325
Practice Address - Country:US
Practice Address - Phone:401-456-2000
Practice Address - Fax:401-456-6554
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPPNS00073101YM0800X
CA21544363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIQ64039Medicare UPIN