Healthcare Provider Details

I. General information

NPI: 1659294619
Provider Name (Legal Business Name): KAITLYN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 COURT ST STE 220B
BOSTON MA
02108-2104
US

IV. Provider business mailing address

169 MADISON AVE STE 38165
NEW YORK NY
10016-5101
US

V. Phone/Fax

Practice location:
  • Phone: 888-963-1828
  • Fax:
Mailing address:
  • Phone: 888-963-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: