Provider Demographics
NPI:1821491234
Name:SULLIVAN, RICKI ELISE
Entity Type:Individual
Prefix:
First Name:RICKI
Middle Name:ELISE
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 1:16 MAYBROOK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2743
Mailing Address - Country:US
Mailing Address - Phone:845-636-4344
Mailing Address - Fax:845-636-4355
Practice Address - Street 1:502 MCKNIGHT DR
Practice Address - Street 2:SUITE 103
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7050
Practice Address - Country:US
Practice Address - Phone:919-217-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist