Provider Demographics
NPI:1902989957
Name:SULLIVAN, TRACY (NP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
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 1:3001 EXPRESSWAY DRIVE NORTH
Mailing Address - Street 2:SUITE #116
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749
Mailing Address - Country:US
Mailing Address - Phone:631-292-6747
Mailing Address - Fax:631-292-6767
Practice Address - Street 1:3001 EXPRESSWAY DRIVE NORTH
Practice Address - Street 2:SUITE #116
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749
Practice Address - Country:US
Practice Address - Phone:631-292-6747
Practice Address - Fax:631-292-6767
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF390010363LP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ15171Medicare ID - Type Unspecified