Provider Demographics
NPI:1811204985
Name:SULLIVAN, KATHLEEN LEA (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LEA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:208
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-755-3279
Mailing Address - Fax:203-755-3057
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:208
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-755-3279
Practice Address - Fax:203-755-3057
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4478363LF0000X
CT004478363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics