Provider Demographics
NPI:1427010057
Name:SULLIVAN, MAUREEN (CNM, WHNP)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:STE 222
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5942
Mailing Address - Country:US
Mailing Address - Phone:907-456-8191
Mailing Address - Fax:907-456-8192
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 217
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-456-8191
Practice Address - Fax:907-456-8192
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420761-1363LW0102X
NYF001104-1367A00000X
MTAPN36126367A00000X
AK1085367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02494035Medicaid
NY02494035Medicaid
NYP95034Medicare UPIN