Healthcare Provider Details

I. General information

NPI: 1689124109
Provider Name (Legal Business Name): DANA R SULLIVAN MSN, RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

125 WHIPPLE ST
PROVIDENCE RI
02908-3258
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-6680
  • Fax:
Mailing address:
  • Phone: 401-854-2504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1170573
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20162082
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN01627
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: