Provider Demographics
NPI:1992713598
Name:SULLIVAN, NANCY L (NP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:
Practice Address - Street 1:295 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8216
Practice Address - Country:US
Practice Address - Phone:716-630-1045
Practice Address - Fax:716-630-1451
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303529-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000560711001OtherHEALTH NOW
NY02292157Medicaid
NY161000580OtherGHI
NY161000580OtherNOVA
NY00026526201OtherUNIVERA
NY9512257OtherIHA