Provider Demographics
NPI:1295345049
Name:SULLIVAN, MEGAN SHANNON
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:SHANNON
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 1:167 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:UXBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01569-2124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:UXBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01569-2124
Practice Address - Country:US
Practice Address - Phone:978-870-3642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2280110163W00000X, 367500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program