Healthcare Provider Details

I. General information

NPI: 1942025408
Provider Name (Legal Business Name): TINA SULLIVAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 GRANITE ST FL 3
MANCHESTER NH
03101-2643
US

IV. Provider business mailing address

65 PLEASANT ST
ANTRIM NH
03440-3405
US

V. Phone/Fax

Practice location:
  • Phone: 603-831-3823
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number08915321
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number08915321
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: