Provider Demographics
NPI:1992041602
Name:SULLIVAN, PHOEBE MANNING (CNM)
Entity Type:Individual
Prefix:
First Name:PHOEBE
Middle Name:MANNING
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 RUTLEDGE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5544
Mailing Address - Country:US
Mailing Address - Phone:617-216-7617
Mailing Address - Fax:
Practice Address - Street 1:2017 RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5544
Practice Address - Country:US
Practice Address - Phone:617-216-7617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI193620-30163W00000X
WI148874-32367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse