Provider Demographics
NPI:1538289533
Name:SULLIVAN, LORETTA (NP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 E 149TH ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3907
Mailing Address - Country:US
Mailing Address - Phone:718-402-0743
Mailing Address - Fax:718-402-9874
Practice Address - Street 1:391 E 149TH ST
Practice Address - Street 2:SUITE 405
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3907
Practice Address - Country:US
Practice Address - Phone:718-402-0743
Practice Address - Fax:718-402-9874
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330276-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily