Healthcare Provider Details

I. General information

NPI: 1043121734
Provider Name (Legal Business Name): CHARLY SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 WORCESTER RD STE 103
CHARLTON MA
01507-1677
US

IV. Provider business mailing address

159 WORCESTER RD STE 103
CHARLTON MA
01507-1677
US

V. Phone/Fax

Practice location:
  • Phone: 508-469-3168
  • Fax: 508-302-8561
Mailing address:
  • Phone: 508-469-3168
  • Fax: 508-302-8561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: