Provider Demographics
NPI:1366819179
Name:SULLIVAN, NICOLE ALYSSA (MA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ALYSSA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 DAFFODIL AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-3815
Mailing Address - Country:US
Mailing Address - Phone:516-655-4031
Mailing Address - Fax:
Practice Address - Street 1:146 DAFFODIL AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-3815
Practice Address - Country:US
Practice Address - Phone:516-655-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist