Provider Demographics
NPI:1588208672
Name:SULLIVAN, KATHERINE (PMHNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 5TH AVE STE 1722
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10175-0003
Mailing Address - Country:US
Mailing Address - Phone:917-740-5287
Mailing Address - Fax:
Practice Address - Street 1:521 5TH AVE STE 1722
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10175-0003
Practice Address - Country:US
Practice Address - Phone:917-740-5287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY779773251J00000X
NY403481363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No251J00000XAgenciesNursing Care