Provider Demographics
NPI:1679644900
Name:SULLIVAN, NANCY M (CNP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 WASHINGTON ST
Mailing Address - Street 2:SUITE 546
Mailing Address - City:NEWTON LOWER FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-964-5020
Mailing Address - Fax:617-964-3033
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:SUITE 546
Practice Address - City:NEWTON LOWER FALLS
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-964-5020
Practice Address - Fax:617-964-3033
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2386OtherBLUE SHIELD
MA0320226Medicaid
MA8301986OtherEVERCARE
MANP2386Medicare ID - Type Unspecified
MA0320226Medicaid