Healthcare Provider Details

I. General information

NPI: 1275627713
Provider Name (Legal Business Name): MARY SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 ANGLING ROAD
PORTAGE MI
49024
US

IV. Provider business mailing address

5943 STADIUM DRIVE SUITE 3
KALAMAZOO MI
49009
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-0944
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704209403
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: