Provider Demographics
NPI:1649367061
Name:SULLIVAN, NICOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:ANCONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:158 W 27TH ST
Mailing Address - Street 2:11TH FLOOR SOUTH
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6216
Mailing Address - Country:US
Mailing Address - Phone:212-563-2497
Mailing Address - Fax:212-563-0605
Practice Address - Street 1:699 92ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-3619
Practice Address - Country:US
Practice Address - Phone:212-563-2497
Practice Address - Fax:212-563-0605
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant