Provider Demographics
NPI:1659847416
Name:SULLIVAN, TERESA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GRAND STREET, 3RD FL
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-368-5000
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4812
Practice Address - Country:US
Practice Address - Phone:845-368-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily