Healthcare Provider Details

I. General information

NPI: 1053584789
Provider Name (Legal Business Name): JENNIFER MAE SULLIVAN WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OSBORNE RD NE SUITE 200
FRIDLEY MN
55432-2774
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-786-6011
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR1564338
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: