Provider Demographics
NPI:1083880181
Name:SULLIVAN, JUDITH EILEEN (ANP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:EILEEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 GOLDEN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3217
Mailing Address - Country:US
Mailing Address - Phone:208-343-0436
Mailing Address - Fax:
Practice Address - Street 1:223 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6013
Practice Address - Country:US
Practice Address - Phone:208-343-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNS36A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health