Healthcare Provider Details

I. General information

NPI: 1245538669
Provider Name (Legal Business Name): KEVIN JOHN SULLIVAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 PALE SAN VITORES RD
TAMUNING GU
96913-3615
US

IV. Provider business mailing address

369 FARENHOLT AVE
TAMUNING GU
96913-3106
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-4542
  • Fax:
Mailing address:
  • Phone: 671-787-8627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA000407
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9237910
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNP0152
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: