Provider Demographics
NPI:1669450144
Name:SULLIVAN, KELSI (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MORGAN CT
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NH
Mailing Address - Zip Code:03870-2033
Mailing Address - Country:US
Mailing Address - Phone:781-254-8837
Mailing Address - Fax:
Practice Address - Street 1:244 N CONGRESS AVE # 2A
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-4212
Practice Address - Country:US
Practice Address - Phone:888-760-4266
Practice Address - Fax:203-774-4636
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1536363A00000X, 363AS0400X
TXPA16652363A00000X
FLPA9116863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P74147Medicare UPIN
MAAP1841Medicare UPIN