Healthcare Provider Details

I. General information

NPI: 1265424121
Provider Name (Legal Business Name): CHRISTINE ANN SULLIVAN CNM, FNP, PHD, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR BLDG 6 5TH FLOOR CREDENTIALING
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

34800 BOB WILSON DR BLDG 6 5TH FLOOR CREDENTIALING
SAN DIEGO CA
92134-5000
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6471
  • Fax:
Mailing address:
  • Phone: 619-532-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13187
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number548
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number393917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: