Provider Demographics
NPI:1265890909
Name:SULLIVAN, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
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 1:2040 9TH AVE
Mailing Address - Street 2:# C
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-2952
Mailing Address - Country:US
Mailing Address - Phone:808-754-4176
Mailing Address - Fax:
Practice Address - Street 1:2040 9TH AVE
Practice Address - Street 2:# C
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-2952
Practice Address - Country:US
Practice Address - Phone:808-754-4176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-1154364SP0812X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community