Provider Demographics
NPI:1750922449
Name:SULLIVAN, TYLER MATTHEW (RN)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:MATTHEW
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5513
Mailing Address - Country:US
Mailing Address - Phone:978-912-1967
Mailing Address - Fax:
Practice Address - Street 1:14 PORTER ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128
Practice Address - Country:US
Practice Address - Phone:617-569-3189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2295420163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult