Healthcare Provider Details

I. General information

NPI: 1285720029
Provider Name (Legal Business Name): MICHELE SULLIVAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 STATE ST
SPRINGFIELD MA
01103-1950
US

IV. Provider business mailing address

273 STATE ST
SPRINGFIELD MA
01103-1950
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-3668
  • Fax: 413-731-8651
Mailing address:
  • Phone: 413-736-3668
  • Fax: 413-731-8651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN: 146884
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: