Provider Demographics
NPI:1578670840
Name:SULLIVAN, CASEY (FNP)
Entity Type:Individual
Prefix:
First Name:CASEY
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 1:1055 N 300 W
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3381
Mailing Address - Country:US
Mailing Address - Phone:801-357-7377
Mailing Address - Fax:801-357-7378
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:STE 108
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3381
Practice Address - Country:US
Practice Address - Phone:801-357-7377
Practice Address - Fax:801-357-7378
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO167224363LF0000X
UT7344974-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO606223Medicaid