Provider Demographics
NPI:1679847107
Name:SULLIVAN, JACQUELINE YVONNE (CNM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:YVONNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:
Practice Address - Street 1:1165 IMPERIAL DR STE 200
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6583
Practice Address - Country:US
Practice Address - Phone:301-665-9098
Practice Address - Fax:301-665-9096
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010272367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102733511Medicaid
PA239521LN7Medicare PIN