Provider Demographics
NPI:1942025408
Name:SULLIVAN, TINA (RN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ANTRIM
Mailing Address - State:NH
Mailing Address - Zip Code:03440-3405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:186 GRANITE ST FL 3
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-2643
Practice Address - Country:US
Practice Address - Phone:603-831-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH08915321163WP0200X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics