Healthcare Provider Details

I. General information

NPI: 1972966083
Provider Name (Legal Business Name): KATHRYN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE RM M1097
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

1240 42ND AVE
SAN FRANCISCO CA
94122-1209
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-0735
  • Fax:
Mailing address:
  • Phone: 847-323-7985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA154680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: