Provider Demographics
NPI:1003929373
Name:SULLIVAN, MARILYN (NP)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 EMPIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2103
Mailing Address - Country:US
Mailing Address - Phone:585-670-0507
Mailing Address - Fax:585-645-0939
Practice Address - Street 1:1527 EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2103
Practice Address - Country:US
Practice Address - Phone:585-670-0507
Practice Address - Fax:585-645-0939
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400291101YM0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400000856Medicare PIN