Provider Demographics
NPI:1225664170
Name:SULLIVAN, MEAGAN M
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:M
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 1:1947 FRONT ST STE 3
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1704
Mailing Address - Country:US
Mailing Address - Phone:516-214-0760
Mailing Address - Fax:516-214-0758
Practice Address - Street 1:1947 FRONT ST STE 3
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1704
Practice Address - Country:US
Practice Address - Phone:516-214-0760
Practice Address - Fax:516-214-0758
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309601363L00000X, 363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology