Provider Demographics
NPI:1013348119
Name:SULLIVAN, COLLEEN MARIE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 MILL ST
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:DUDLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01571-3373
Mailing Address - Country:US
Mailing Address - Phone:508-826-2335
Mailing Address - Fax:
Practice Address - Street 1:42 MILL ST
Practice Address - Street 2:APARTMENT 2
Practice Address - City:DUDLEY
Practice Address - State:MA
Practice Address - Zip Code:01571-3373
Practice Address - Country:US
Practice Address - Phone:508-826-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-29
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program