Healthcare Provider Details

I. General information

NPI: 1194989947
Provider Name (Legal Business Name): CATHERINE SULLIVAN-WHITESIDE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTHEAST HEALTH CENTER 5400 EAST 7 MILE ROAD ROOM 16
DETROIT MI
48235
US

IV. Provider business mailing address

NORTHEAST HEALTH CENTER 5400 EAST 7 MILE ROAD ROOM 16
DETROIT MI
48235
US

V. Phone/Fax

Practice location:
  • Phone: 313-870-3049
  • Fax: 313-368-4694
Mailing address:
  • Phone: 313-870-3049
  • Fax: 313-368-4694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704176626
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: