Provider Demographics
NPI:1659401347
Name:SULLIVAN, JUDITH ANN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:JUDITH
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E 70TH ST
Mailing Address - Street 2:# 102
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-8629
Mailing Address - Country:US
Mailing Address - Phone:212-592-4066
Mailing Address - Fax:
Practice Address - Street 1:2453 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5705
Practice Address - Country:US
Practice Address - Phone:718-882-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239541-1164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01555462Medicaid