Provider Demographics
NPI:1033752530
Name:SULLIVAN, CRYSTAL JEAN (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24661 COUNTY RD S
Mailing Address - Street 2:
Mailing Address - City:BRUSH
Mailing Address - State:CO
Mailing Address - Zip Code:80723-9703
Mailing Address - Country:US
Mailing Address - Phone:970-371-7183
Mailing Address - Fax:
Practice Address - Street 1:2500 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2639
Practice Address - Country:US
Practice Address - Phone:701-456-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995068-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily