MEDICARE: LORETTA SULLIVAN NP

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	363LF0000X	Family Nurse Practitioner	F330276-1	NY

General Provider Information

NPI Number	:	1538289533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORETTA SULLIVAN NP

Provider Business Mailing Address
First Line	:	391 E 149TH ST
Second Line	:	SUITE 405
City	:	BRONX
State	:	NY
Zip	:	10455-3907
Country	:	US
Telephone Number	:	718-402-0743
Fax Number	:	718-402-9874

Provider Business Practice Location Address
First Line	:	391 E 149TH ST
Second Line	:	SUITE 405
City	:	BRONX
State	:	NY
Zip	:	10455-3907
Country	:	US
Telephone Number	:	718-402-0743
Fax Number	:	718-402-9874

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

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	08/01/2011

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