Provider Demographics
NPI:1528586971
Name:O'SULLIVAN, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:O'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 1:6 SHUTE AVE
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1228
Mailing Address - Country:US
Mailing Address - Phone:781-835-6124
Mailing Address - Fax:
Practice Address - Street 1:6 SHUTE AVE
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-1228
Practice Address - Country:US
Practice Address - Phone:781-835-6124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
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
9AM00106259OtherCVS CAREMARK
APHAN6567668OtherBLUE CROSS ANTHEM
04543OtherDELTA DENTAL- AMPHENOL GROUP