MEDICARE: DEVIN CLAIRE SULLIVAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363LF0000X	Family Nurse Practitioner	13185640-4405	UT

General Provider Information

NPI Number	:	1942955471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVIN CLAIRE SULLIVAN FNP

Provider Business Mailing Address
First Line	:	19 HASTINGS PL
Second Line	:
City	:	MONMOUTH BEACH
State	:	NJ
Zip	:	07750-1104
Country	:	US
Telephone Number	:	732-233-5397
Fax Number	:

Provider Business Practice Location Address
First Line	:	4088 W 1820 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-4885
Country	:	US
Telephone Number	:	801-975-7799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2022
Last Update Date	:	02/22/2023

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