Provider Demographics
NPI:1205383890
Name:SULLIVAN, HEATHER (FNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:110 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9157
Mailing Address - Country:US
Mailing Address - Phone:541-347-2313
Mailing Address - Fax:
Practice Address - Street 1:110 10TH ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9157
Practice Address - Country:US
Practice Address - Phone:541-347-2313
Practice Address - Fax:541-347-2015
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200341475RN163W00000X
AK117094363LF0000X
OR201607221NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500766156Medicaid