Provider Demographics
NPI:1861737140
Name:SULLIVAN, JODI-LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:JODI-LYNN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 PLATTEKILL ARDONIA RD
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-4636
Mailing Address - Country:US
Mailing Address - Phone:845-597-9963
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-797-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY90925367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered