Provider Demographics
NPI:1871082636
Name:SULLIVAN, ELIZABETH THERESA (CNS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:THERESA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:4 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-662-2300
Mailing Address - Fax:215-614-0418
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:4 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-2300
Practice Address - Fax:215-614-0418
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN304635L163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator