Provider Demographics
NPI:1770139123
Name:SULLIVAN, STAYCE K
Entity type:Individual
Prefix:
First Name:STAYCE
Middle Name:K
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 1:42 GRANDE PASEO
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1546
Mailing Address - Country:US
Mailing Address - Phone:509-995-7310
Mailing Address - Fax:
Practice Address - Street 1:515 NORTHGATE DR.
Practice Address - Street 2:STE. 101
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-9490
Practice Address - Country:US
Practice Address - Phone:415-202-9990
Practice Address - Fax:415-202-0102
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012073363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care