Provider Demographics
NPI:1346497757
Name:SULLIVAN, COURTNEY D (ACNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BECKMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:SUITE 363
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6255
Mailing Address - Fax:
Practice Address - Street 1:8111 DODGE ST
Practice Address - Street 2:SUITE 363
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4129
Practice Address - Country:US
Practice Address - Phone:402-354-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007230363LA2100X
NE111234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098941007Medicare PIN
IL569810002Medicare PIN