Provider Demographics
NPI:1649613241
Name:SULLIVAN, MICHELLE LOUISE (LPN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 DANBY RD
Mailing Address - Street 2:
Mailing Address - City:WILLSEYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13864-1004
Mailing Address - Country:US
Mailing Address - Phone:607-351-8130
Mailing Address - Fax:
Practice Address - Street 1:2167 DANBY RD
Practice Address - Street 2:
Practice Address - City:WILLSEYVILLE
Practice Address - State:NY
Practice Address - Zip Code:13864-1004
Practice Address - Country:US
Practice Address - Phone:607-351-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285400164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse