Provider Demographics
NPI:1770615585
Name:SULLIVAN, AMY BETH (NP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
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 6369
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-6369
Mailing Address - Country:US
Mailing Address - Phone:406-447-2823
Mailing Address - Fax:406-447-2760
Practice Address - Street 1:3330 PTARMIGAN LN
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602
Practice Address - Country:US
Practice Address - Phone:406-457-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22036363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4307823Medicaid
MT000084981Medicare ID - Type Unspecified
MTQ55270Medicare UPIN