Healthcare Provider Details

I. General information

NPI: 1205179066
Provider Name (Legal Business Name): KATHRYN SULLIVAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 03/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 EL CAMINO REAL
CARLSBAD CA
92008-1273
US

IV. Provider business mailing address

1733 S NEVADA ST
OCEANSIDE CA
92054-6022
US

V. Phone/Fax

Practice location:
  • Phone: 186-638-9272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: