Provider Demographics
NPI:1427392687
Name:SULLIVAN, GINA MARIE (APNP)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:ZLOTOCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:125 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3303
Mailing Address - Country:US
Mailing Address - Phone:920-390-7575
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-390-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4989-33363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner