Provider Demographics
NPI:1669228573
Name:CULLISON, ANNIKA I
Entity type:Individual
Prefix:MISS
First Name:ANNIKA
Middle Name:I
Last Name:CULLISON
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 1:10400 W BARNSDALE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-1923
Mailing Address - Country:US
Mailing Address - Phone:208-609-0660
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-396-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician