Healthcare Provider Details

I. General information

NPI: 1205383890
Provider Name (Legal Business Name): HEATHER SULLIVAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 10TH ST SE
BANDON OR
97411-9157
US

IV. Provider business mailing address

110 10TH ST SE
BANDON OR
97411-9157
US

V. Phone/Fax

Practice location:
  • Phone: 541-347-2313
  • Fax: 541-347-2015
Mailing address:
  • Phone: 541-347-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number117094
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200341475RN
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201607221NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: