Provider Demographics
NPI:1033411632
Name:SULLIVAN, MAUREEN
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PEARSON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:347-350-1259
Mailing Address - Fax:
Practice Address - Street 1:28-11 QUEENS PLAZA
Practice Address - Street 2:
Practice Address - City:LIC
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-391-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY487406163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse