Provider Demographics
NPI:1487021614
Name:SULLIVAN, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:TROMPETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:146 HAMPTON PKWY
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1242
Mailing Address - Country:US
Mailing Address - Phone:585-313-6774
Mailing Address - Fax:
Practice Address - Street 1:4242 RIDGE LEA RD STE 2
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-5122
Practice Address - Country:US
Practice Address - Phone:716-819-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1261831390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program