Healthcare Provider Details

I. General information

NPI: 1043848633
Provider Name (Legal Business Name): MARYBETH SULLIVAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 DEKALB ST
NORRISTOWN PA
19401-3405
US

IV. Provider business mailing address

1412 FAIRMOUNT AVE
PHILADELPHIA PA
19130-2908
US

V. Phone/Fax

Practice location:
  • Phone: 484-751-6241
  • Fax:
Mailing address:
  • Phone: 215-235-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN507395L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: