Provider Demographics
NPI:1144831603
Name:SULLIVAN, COURTNEY LOUISE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LOUISE
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 1:1176 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6503
Mailing Address - Country:US
Mailing Address - Phone:212-241-3300
Mailing Address - Fax:212-202-4590
Practice Address - Street 1:1 GUSTAVE LEVY PL.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-241-3806
Practice Address - Fax:212-202-4590
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723317163W00000X
NY346579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse