Active NPI
Maryellen Sullivan, NP
- Adult Health Nurse Practitioner
- Waltham, MA
National Provider Identifier
1306812086
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Adult Health Nurse Practitioner
- License
- 142612
- Practice address
- 950 Winter Street
Waltham, MA 02451 - Phone
- (781) 472-8787
- NPI assigned
- Feb 23, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Adult Health Nurse Practitioner | 363LA2200X | 142612 | MA | Primary |
Addresses
Primary practice location
950 Winter Street
Waltham, MA 02451
Mailing address
1200 Centre St
Dept. of Medicine
Roslindale, MA 02131-1011
Phone (617) 363-8010
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 142612 | MA | MD | Adult Health Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Evercare Collaborative Solutions Inc | Past | Accepting new patients | |
| Optum Care Services Company | Adult Health | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
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NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1140652800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1442448000000",
"number": "1306812086",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1200 CENTRE ST",
"address_2": "DEPT. OF MEDICINE",
"city": "ROSLINDALE",
"state": "MA",
"postal_code": "021311011",
"telephone_number": "617-363-8010",
"fax_number": "617-363-8929"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "950 WINTER STREET",
"city": "WALTHAM",
"state": "MA",
"postal_code": "02451",
"telephone_number": "781-472-8787"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SULLIVAN",
"first_name": "MARYELLEN",
"credential": "NP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-02-23",
"last_updated": "2015-09-17",
"status": "A"
},
"taxonomies": [
{
"code": "363LA2200X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Adult Health",
"state": "MA",
"license": "142612",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Waltham, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 17, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.