Provider Demographics
NPI:1518637164
Name:SULLIVAN, KAILA (FNP)
Entity Type:Individual
Prefix:
First Name:KAILA
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 1:620 NW 11TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6712
Mailing Address - Country:US
Mailing Address - Phone:541-289-4118
Mailing Address - Fax:541-667-3484
Practice Address - Street 1:1050 W ELM AVE STE 110
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2713
Practice Address - Country:US
Practice Address - Phone:541-567-2995
Practice Address - Fax:541-567-7720
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202106596NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner