Provider Demographics
NPI:1558970251
Name:SULLIVAN, KATIE MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8630 FENTON ST STE 1204
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3808
Mailing Address - Country:US
Mailing Address - Phone:240-839-5811
Mailing Address - Fax:301-495-0318
Practice Address - Street 1:8630 FENTON ST STE 1200
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3808
Practice Address - Country:US
Practice Address - Phone:240-839-5811
Practice Address - Fax:301-495-0318
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR240224363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner