Provider Demographics
NPI:1336600782
Name:SULLIVAN, NICKOLAS ALLAN (HIS)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:ALLAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6253 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8730
Mailing Address - Country:US
Mailing Address - Phone:315-452-1600
Mailing Address - Fax:315-288-5434
Practice Address - Street 1:6253 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8730
Practice Address - Country:US
Practice Address - Phone:315-452-1600
Practice Address - Fax:315-288-5434
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000056727237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist