Healthcare Provider Details

I. General information

NPI: 1578227682
Provider Name (Legal Business Name): KRISTEN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W 203RD ST STE 201
OLYMPIA FIELDS IL
60461-1185
US

IV. Provider business mailing address

3800 W 203RD ST STE 201
OLYMPIA FIELDS IL
60461-1185
US

V. Phone/Fax

Practice location:
  • Phone: 708-852-2699
  • Fax:
Mailing address:
  • Phone: 708-852-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023522
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: