Provider Demographics
NPI:1689602435
Name:SULLIVAN, JANNA MARIE (WHCNP)
Entity Type:Individual
Prefix:
First Name:JANNA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3765
Mailing Address - Country:US
Mailing Address - Phone:406-752-8282
Mailing Address - Fax:406-257-2225
Practice Address - Street 1:75 CLAREMONT ST
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3585
Practice Address - Country:US
Practice Address - Phone:406-752-8282
Practice Address - Fax:406-257-2225
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN9728363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4302415Medicaid
MTP13323Medicare UPIN