Provider Demographics
NPI:1710255021
Name:SULLIVAN, KRISTEN RUDICK (RN, MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RUDICK
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN, MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:508-334-8765
Mailing Address - Fax:774-443-7360
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-8765
Practice Address - Fax:774-443-7360
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN284023363L00000X, 363LP0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics