Provider Demographics
NPI:1780299834
Name:SULLIVAN, BEBIELYN A (LPN)
Entity type:Individual
Prefix:MRS
First Name:BEBIELYN
Middle Name:A
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 1:736 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1751
Mailing Address - Country:US
Mailing Address - Phone:585-752-0001
Mailing Address - Fax:
Practice Address - Street 1:736 EAST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1751
Practice Address - Country:US
Practice Address - Phone:585-752-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336969164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty