Provider Demographics
NPI:1790954816
Name:SULLIVAN, PATRICIA
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-1626
Mailing Address - Country:US
Mailing Address - Phone:970-874-2165
Mailing Address - Fax:970-874-2175
Practice Address - Street 1:255 W 6TH ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-1626
Practice Address - Country:US
Practice Address - Phone:970-874-2165
Practice Address - Fax:970-874-2175
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2050363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07020506Medicaid