Provider Demographics
NPI:1225664170
Name:SULLIVAN, MEAGAN M
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 ROUTE 109 STE A
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1158
Mailing Address - Country:US
Mailing Address - Phone:631-383-9967
Mailing Address - Fax:631-397-0919
Practice Address - Street 1:910 ROUTE 109 STE A
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1158
Practice Address - Country:US
Practice Address - Phone:631-991-3235
Practice Address - Fax:631-397-0919
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309601363L00000X, 363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology