Provider Demographics
NPI:1205199601
Name:SULLIVAN, TARA MARIE
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:STAVRIANEAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14911 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1725
Mailing Address - Country:US
Mailing Address - Phone:516-576-2040
Mailing Address - Fax:
Practice Address - Street 1:14911 12TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1725
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1718799174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist