Provider Demographics
NPI:1114320116
Name:SULLIVAN, TERRI JEAN
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19715 WAR ADMIRAL RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8473
Mailing Address - Country:US
Mailing Address - Phone:907-726-0662
Mailing Address - Fax:
Practice Address - Street 1:19715 WAR ADMIRAL RD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8473
Practice Address - Country:US
Practice Address - Phone:907-726-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK35531163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse