Provider Demographics
NPI:1336906528
Name:SULLIVAN, CRISTIANNA F (MD,)
Entity Type:Individual
Prefix:
First Name:CRISTIANNA
Middle Name:F
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HOKANSON LN UPPR GRANDE
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-5114
Mailing Address - Country:US
Mailing Address - Phone:208-487-4839
Mailing Address - Fax:
Practice Address - Street 1:25 HOKANSON LN UPPR GRANDE
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-5114
Practice Address - Country:US
Practice Address - Phone:208-487-4839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2813089133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric