Healthcare Provider Details

I. General information

NPI: 1083880181
Provider Name (Legal Business Name): JUDITH EILEEN SULLIVAN ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 W STATE ST
BOISE ID
83702-6013
US

IV. Provider business mailing address

43 GOLDEN EAGLE DR
BOISE ID
83716-3217
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-0436
  • Fax:
Mailing address:
  • Phone: 208-343-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberCNS36A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: