Healthcare Provider Details

I. General information

NPI: 1659847416
Provider Name (Legal Business Name): TERESA ANN SULLIVAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 LAFAYETTE AVE
SUFFERN NY
10901-4812
US

IV. Provider business mailing address

20 GRAND STREET, 3RD FL
WARWICK NY
10990-1035
US

V. Phone/Fax

Practice location:
  • Phone: 845-368-5029
  • Fax:
Mailing address:
  • Phone: 845-368-5000
  • Fax: 845-987-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343700
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: