Provider Demographics
NPI:1639320336
Name:SULLIVAN, KATHLEEN CONNELLY (MS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:CONNELLY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DOVER CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-1548
Mailing Address - Country:US
Mailing Address - Phone:508-212-2838
Mailing Address - Fax:
Practice Address - Street 1:2 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP2616363A00000X
RIPA00667363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant