Provider Demographics
NPI:1801995493
Name:SULLIVAN, LORRAINE (NP)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 BLUE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1209
Mailing Address - Country:US
Mailing Address - Phone:516-810-0475
Mailing Address - Fax:631-732-6592
Practice Address - Street 1:1747 VETERANS HWY STE 24
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1534
Practice Address - Country:US
Practice Address - Phone:631-853-7300
Practice Address - Fax:631-853-7301
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400014174400000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR48881Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER