Healthcare Provider Details

I. General information

NPI: 1033778360
Provider Name (Legal Business Name): JENNIFER SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WAKE FOREST RD
RALEIGH NC
27609-7317
US

IV. Provider business mailing address

929 GABRIEL DR APT 104
GREENVILLE NC
27834-2196
US

V. Phone/Fax

Practice location:
  • Phone: 617-595-2739
  • Fax:
Mailing address:
  • Phone: 617-595-2739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2328056
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: