Provider Demographics
NPI:1093950420
Name:SULLIVAN, DEBORAH LEE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:LEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3706 N STONE CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-4745
Mailing Address - Country:US
Mailing Address - Phone:208-514-3217
Mailing Address - Fax:
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4882
Practice Address - Country:US
Practice Address - Phone:208-454-0567
Practice Address - Fax:208-402-6635
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP891363LP2300X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health