Provider Demographics
NPI:1912908740
Name:SULLIVAN, JACQUELYN MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 ERWIN RD
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4699
Mailing Address - Country:US
Mailing Address - Phone:919-864-8111
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-864-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2017-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08877363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200191600Medicaid
INS81043Medicare UPIN
IN200191600Medicaid