Healthcare Provider Details

I. General information

NPI: 1205926508
Provider Name (Legal Business Name): MAURA ANN SULLIVAN-MOORE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
JAMAICA PLAIN MA
02130-4817
US

IV. Provider business mailing address

175 HIGH ST
DUXBURY MA
02332-3428
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-9500
  • Fax:
Mailing address:
  • Phone: 781-585-2076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number123432
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: