1205648672 NPI number — MRS. KERI SULLIVAN PHD STUDENT

Table of content: MRS. KERI SULLIVAN PHD STUDENT (NPI 1205648672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205648672 NPI number — MRS. KERI SULLIVAN PHD STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
KERI
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHD STUDENT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205648672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 WESTGATE DR APT 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-6434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
339-223-6660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MERRIMACK ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01852-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-455-0756
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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