Provider Demographics
NPI:1053735282
Name:SULLIVAN, MARY KATHLEEN (DNP, FNP, RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DNP, FNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 KIRBY PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3654
Mailing Address - Country:US
Mailing Address - Phone:901-334-5464
Mailing Address - Fax:901-334-5466
Practice Address - Street 1:1920 KIRBY PKWY STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3654
Practice Address - Country:US
Practice Address - Phone:901-334-5464
Practice Address - Fax:901-334-5466
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 12894363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care