Healthcare Provider Details

I. General information

NPI: 1033022892
Provider Name (Legal Business Name): LILY SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3739
  • Fax: 617-667-7292
Mailing address:
  • Phone: 617-667-3739
  • Fax: 617-667-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN10009019
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: