Provider Demographics
NPI:1689898561
Name:SULLIVAN, DONNA M (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 WEDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-1204
Mailing Address - Country:US
Mailing Address - Phone:516-581-6594
Mailing Address - Fax:
Practice Address - Street 1:49 WEDGEWOOD LN
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-1204
Practice Address - Country:US
Practice Address - Phone:516-581-6594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ18R41Medicare ID - Type Unspecified