Provider Demographics
NPI:1770916959
Name:SULLIVAN, COLLEEN MARIE (RN/NP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN/NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE VALLEY
Mailing Address - State:NH
Mailing Address - Zip Code:03215-0537
Mailing Address - Country:US
Mailing Address - Phone:978-771-8886
Mailing Address - Fax:
Practice Address - Street 1:79 SWIFTWATER RD
Practice Address - Street 2:
Practice Address - City:WOODSVILLE
Practice Address - State:NH
Practice Address - Zip Code:03785-1447
Practice Address - Country:US
Practice Address - Phone:603-747-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH083892-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty