Provider Demographics
NPI:1710031232
Name:SULLIVAN, NANCY H (CNM)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:H
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3178
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST
Practice Address - Street 2:SUITE 114
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1763
Practice Address - Country:US
Practice Address - Phone:503-215-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR085084366N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife