Provider Demographics
NPI:1639423734
Name:SULLIVAN, JILLIAN ANN (APRN)
Entity Type:Individual
Prefix:MISS
First Name:JILLIAN
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SHAGBARK DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3220
Mailing Address - Country:US
Mailing Address - Phone:860-940-8132
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2212
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:860-679-4474
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005128363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1639423734Medicaid