Provider Demographics
NPI:1073382032
Name:WASKOSKY, SULLIVAN (APRN, CNM)
Entity type:Individual
Prefix:
First Name:SULLIVAN
Middle Name:
Last Name:WASKOSKY
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEADOW PROGRAM, VUSN 461 21ST AVE S
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37240
Mailing Address - Country:US
Mailing Address - Phone:615-343-2683
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2501
Practice Address - Country:US
Practice Address - Phone:217-383-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209032525367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife