Provider Demographics
NPI:1790184273
Name:SULLY, ESMERALDA
Entity type:Individual
Prefix:
First Name:ESMERALDA
Middle Name:
Last Name:SULLY
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 1:5542 METROWEST BLVD
Mailing Address - Street 2:APT 105
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-2449
Mailing Address - Country:US
Mailing Address - Phone:407-990-0246
Mailing Address - Fax:
Practice Address - Street 1:5542 METROWEST BLVD
Practice Address - Street 2:APT 105
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-2449
Practice Address - Country:US
Practice Address - Phone:407-990-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010386600Medicaid