Provider Demographics
NPI:1750689311
Name:SULLIVAN, MALLORY (PA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:SCHNARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0021394OtherRI MEDICARE
RIMS84572Medicaid
RI06-09-2011OtherNHPRI
RI06012011OtherUNITED HEALTHCARE
RI06-18-2011OtherBCBSRI
RI939025129OtherRI MEDICARE GROUP