Provider Demographics
NPI:1912291436
Name:SULLIVAN, AMANDA (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:364 LAKE MARIE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-2924
Mailing Address - Country:US
Mailing Address - Phone:845-866-1667
Mailing Address - Fax:
Practice Address - Street 1:364 LAKE MARIE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2924
Practice Address - Country:US
Practice Address - Phone:845-866-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286438164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse