Provider Demographics
NPI:1821116914
Name:SULLENS, MARY MARTIN (RN FNP MHS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARTIN
Last Name:SULLENS
Suffix:
Gender:F
Credentials:RN FNP MHS
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Mailing Address - Street 1:3345 TIMBERCREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002
Mailing Address - Country:US
Mailing Address - Phone:530-227-1840
Mailing Address - Fax:530-225-7293
Practice Address - Street 1:2625 EDITH AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001
Practice Address - Country:US
Practice Address - Phone:530-225-7480
Practice Address - Fax:530-225-7293
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CANPF 6314363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPF 6314OtherNURSE PRACT. LICENSE
CARN 229515OtherLICENSE NUMBER