Provider Demographics
NPI:1528236924
Name:SULLIVAN, SHELLEY K (LIC AC)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:K
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 COMMODORE CT
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:MA
Mailing Address - Zip Code:02045-1317
Mailing Address - Country:US
Mailing Address - Phone:781-545-1345
Mailing Address - Fax:
Practice Address - Street 1:132 FRONT ST
Practice Address - Street 2:SUITE 303
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-1386
Practice Address - Country:US
Practice Address - Phone:781-545-1345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA173171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist