Healthcare Provider Details

I. General information

NPI: 1063208593
Provider Name (Legal Business Name): STEPHEN D SULLIVAN RN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

814 EASTSIDE ST NE # BE
OLYMPIA WA
98506-4032
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-4100
  • Fax:
Mailing address:
  • Phone: 360-319-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN60082129
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: