Provider Demographics
NPI:1245985688
Name:SULLIVAN, KEELY (NP)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:151 QUARRY LN
Mailing Address - Street 2:
Mailing Address - City:SWANTON
Mailing Address - State:VT
Mailing Address - Zip Code:05488-8946
Mailing Address - Country:US
Mailing Address - Phone:518-569-2886
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:518-569-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0135179363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care