Provider Demographics
NPI:1972644862
Name:SULLIVAN, MARGARET M (NP)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 EMMONSDALE RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-2975
Mailing Address - Country:US
Mailing Address - Phone:617-325-7582
Mailing Address - Fax:
Practice Address - Street 1:770 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2706
Practice Address - Country:US
Practice Address - Phone:617-524-2121
Practice Address - Fax:617-524-3810
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0388921Medicaid
MANP3763Medicare ID - Type Unspecified
MA0388921Medicaid