Healthcare Provider Details

I. General information

NPI: 1366474165
Provider Name (Legal Business Name): MARY JANE SULLIVAN AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 LIBRARY WAY
DURHAM NH
03824
US

IV. Provider business mailing address

61 LOCKE RD.
HAMPTON NH
03842
US

V. Phone/Fax

Practice location:
  • Phone: 603-862-5077
  • Fax: 603-862-4511
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA449
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number299
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: