Healthcare Provider Details

I. General information

NPI: 1144169947
Provider Name (Legal Business Name): GRACE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W MAIN ST STE 132
STAMFORD CT
06902-4544
US

IV. Provider business mailing address

5 PERRYRIDGE RD
GREENWICH CT
06830-4608
US

V. Phone/Fax

Practice location:
  • Phone: 203-363-0123
  • Fax: 475-619-9855
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12017032
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: