Provider Demographics
NPI:1639537871
Name:SULLIVAN, WONDA
Entity Type:Individual
Prefix:MS
First Name:WONDA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:GUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10736 142ND ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5220
Mailing Address - Country:US
Mailing Address - Phone:718-440-5878
Mailing Address - Fax:718-558-8514
Practice Address - Street 1:10736 142ND ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-5220
Practice Address - Country:US
Practice Address - Phone:718-440-5878
Practice Address - Fax:718-558-8514
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291840-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse