Provider Demographics
NPI:1265424121
Name:SULLIVAN, CHRISTINE ANN (CNM, FNP, PHD, MSN)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNM, FNP, PHD, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:BLDG 6 5TH FLOOR CREDENTIALING
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:619-532-6471
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:BLDG 6 5TH FLOOR CREDENTIALING
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:619-532-6471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393917163WW0101X
CA13187363LF0000X
CA548367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACX971YMedicare PIN
CACX971ZMedicare PIN