Provider Demographics
NPI:1174550586
Name:SULZBACH, HEATHER
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:SULZBACH
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 1:1999 MARCUS AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-466-6611
Mailing Address - Fax:516-466-6611
Practice Address - Street 1:1999 MARCUS AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-466-6611
Practice Address - Fax:516-466-6611
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3041691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q63252Medicare UPIN
NY1531G10Medicare PIN