Provider Demographics
NPI:1730121864
Name:SULLIVAN, STEPHANIE M (MSN, NP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSN, NP
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MAYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, NP
Mailing Address - Street 1:2001 DWIGHT WAY
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2608
Mailing Address - Country:US
Mailing Address - Phone:510-204-5770
Mailing Address - Fax:510-204-5749
Practice Address - Street 1:2001 DWIGHT WAY
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2608
Practice Address - Country:US
Practice Address - Phone:510-204-5770
Practice Address - Fax:510-204-5749
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA566514363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA005665140Medicaid
CA005665140Medicare PIN
CAQ47623Medicare UPIN