Provider Demographics
NPI:1861628893
Name:SULLIVAN, MARY CECILIA (MSN, APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CECILIA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELMCROFT RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06926-0700
Mailing Address - Country:US
Mailing Address - Phone:203-351-7700
Mailing Address - Fax:
Practice Address - Street 1:1 ELMCROFT RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06926-0700
Practice Address - Country:US
Practice Address - Phone:203-351-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001625363LF0000X
NYF380181-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics