Provider Demographics
NPI:1558786640
Name:SULLIVAN, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
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 1:16 CANTON CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-6023
Mailing Address - Country:US
Mailing Address - Phone:718-332-1798
Mailing Address - Fax:
Practice Address - Street 1:16 CANTON CT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-6023
Practice Address - Country:US
Practice Address - Phone:718-332-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY434536-1364SS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SS0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistSchool