Provider Demographics
NPI:1053372110
Name:SULLIVAN, MARY E (NP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-0001
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:119 BELMONT ST
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-5597
Practice Address - Fax:508-334-5089
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA132867363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0348431Medicaid
MANP303401Medicare PIN
MA0348431Medicaid