Provider Demographics
NPI:1649524059
Name:SULLIVAN, KATIE JO (NP)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:JO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JO
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8579 COMMERCE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-7420
Mailing Address - Country:US
Mailing Address - Phone:410-822-9133
Mailing Address - Fax:410-822-9513
Practice Address - Street 1:8579 COMMERCE DR STE 104
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7420
Practice Address - Country:US
Practice Address - Phone:410-822-9133
Practice Address - Fax:410-822-9513
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR166423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409164YBLLMedicare PIN