1821116914 NPI number — MS. MARY MARTIN SULLENS RN FNP MHS

Table of content: MS. MARY MARTIN SULLENS RN FNP MHS (NPI 1821116914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821116914 NPI number — MS. MARY MARTIN SULLENS RN FNP MHS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLENS
Provider First Name:
MARY
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN FNP MHS
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:
1821116914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3345 TIMBERCREEK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-227-1840
Provider Business Mailing Address Fax Number:
530-225-7293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2625 EDITH AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-225-7480
Provider Business Practice Location Address Fax Number:
530-225-7293
Provider Enumeration Date:
03/27/2007

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: 363LX0001X , with the licence number:  NPF 6314 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NPF 6314 . This is a "NURSE PRACT. LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: RN 229515 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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