Healthcare Provider Details

I. General information

NPI: 1558490839
Provider Name (Legal Business Name): KRISTINA SULLY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W BANCROFT ST MS 513
TOLEDO OH
43606-3328
US

IV. Provider business mailing address

1 STABLESIDE S
OTTAWA HILLS OH
43615-2165
US

V. Phone/Fax

Practice location:
  • Phone: 419-530-3451
  • Fax: 419-530-3499
Mailing address:
  • Phone: 419-531-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number111067
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: