Provider Demographics
NPI:1699386771
Name:SULLIVAN, MEGHAN NICOLE
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:NICOLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 SW 50TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-2021
Mailing Address - Country:US
Mailing Address - Phone:954-394-3215
Mailing Address - Fax:
Practice Address - Street 1:301 CAMINO GARDENS BLVD STE 104
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5823
Practice Address - Country:US
Practice Address - Phone:561-494-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30395225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant