Provider Demographics
NPI:1811071863
Name:SULLIVAN, NANCY (PT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE 520
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3097
Mailing Address - Country:US
Mailing Address - Phone:503-413-7556
Mailing Address - Fax:503-413-6547
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 520
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-7556
Practice Address - Fax:503-413-6547
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12501225100000X
OR60187225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR60187OtherOREGON PHYSICAL THERAPY LICENSE