Basic Information
| Provider Information | |||||||||
| NPI: | 1609495472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KAYLEIGH | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 458 OLD STREET RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PETERBOROUGH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034581265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039242144 | ||||||||
| FaxNumber: | 6039243993 | ||||||||
| Practice Location | |||||||||
| Address1: | 458 OLD STREET RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PETERBOROUGH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034581265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039242144 | ||||||||
| FaxNumber: | 6039243993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2020 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.