MEDICARE: GERALDE SULLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	262734	NY

General Provider Information

NPI Number	:	1417303223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALDE SULLY

Provider Business Mailing Address
First Line	:	4141 ELY AVE
Second Line	:	1
City	:	BRONX
State	:	NY
Zip	:	10466-2033
Country	:	US
Telephone Number	:	347-781-2731
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 ELY AVE
Second Line	:	1
City	:	BRONX
State	:	NY
Zip	:	10466-2033
Country	:	US
Telephone Number	:	347-781-2731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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Directions to “ GERALDE SULLY ” Practice Location

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