Healthcare Provider Details

I. General information

NPI: 1780447979
Provider Name (Legal Business Name): MS. SAMANTHA A SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FOREST AVE
BUFFALO NY
14213-1207
US

IV. Provider business mailing address

400 FOREST AVE
BUFFALO NY
14213-1207
US

V. Phone/Fax

Practice location:
  • Phone: 716-885-2261
  • Fax: 716-816-2267
Mailing address:
  • Phone: 716-885-2261
  • Fax: 716-816-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number752761
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: