Provider Demographics
NPI:1023018900
Name:SULLIVAN, DEBORAH A (NP)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 N ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1507
Mailing Address - Country:US
Mailing Address - Phone:719-550-1172
Mailing Address - Fax:719-591-2864
Practice Address - Street 1:2139 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1507
Practice Address - Country:US
Practice Address - Phone:719-550-1172
Practice Address - Fax:719-591-2864
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO69284363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC498198Medicare PIN
COS57118Medicare UPIN
COC71816Medicare PIN