MEDICARE: CARLY MICHELLE SULLIVAN FNP

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	351948	NY

General Provider Information

NPI Number	:	1952188047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY MICHELLE SULLIVAN FNP

Provider Business Mailing Address
First Line	:	33 N JEFFERSON ST
Second Line	:
City	:	CARTHAGE
State	:	NY
Zip	:	13619-1131
Country	:	US
Telephone Number	:	315-771-5266
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 HOWLE AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-2449
Country	:	US
Telephone Number	:	854-444-0518
Fax Number	:

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

Provider Enumeration Date	:	09/12/2023
Last Update Date	:	09/12/2023

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