Healthcare Provider Details

I. General information

NPI: 1851413983
Provider Name (Legal Business Name): JILL PAULA SULLIVAN-KEATING NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/15/2024
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 RANDOLPH RD STE 200
CHARLOTTE NC
28211-1368
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-302-8555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5013058
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5013058
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: