Individual
MALLORY SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
593 EDDY ST, PROVIDENCE, RI 02903-4923
(401) 519-1604
(401) 272-0538
Mailing address
PO BOX 9484, PROVIDENCE, RI 02940-9484
(401) 854-2500
(401) 854-2519
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00585
RI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0021394
RI MEDICARE
RI
01
—
06-09-2011
NHPRI
RI
01
—
06-18-2011
BCBSRI
RI
01
—
06012011
UNITED HEALTHCARE
RI
01
—
939025129
RI MEDICARE GROUP
RI
05
—
MS84572
—
RI
Enumeration date
03/07/2011
Last updated
08/06/2013
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