Provider Demographics
NPI:1932153632
Name:SULLIVAN-OGG, JACQUELINE RUTH (ARNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:RUTH
Last Name:SULLIVAN-OGG
Suffix:
Gender:F
Credentials:ARNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HIGHWAY ST
Mailing Address - Street 2:PO BOX 218
Mailing Address - City:UNDERWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51576-0218
Mailing Address - Country:US
Mailing Address - Phone:712-566-9148
Mailing Address - Fax:712-566-9408
Practice Address - Street 1:401 HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:IA
Practice Address - Zip Code:51576
Practice Address - Country:US
Practice Address - Phone:712-566-9148
Practice Address - Fax:712-566-9408
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-082459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00338315OtherRAILROAD MEDICARE
IA0498329Medicaid
IA270478OtherMEDICARE ID
NE110194OtherARNP LICENSE
IAA- 082459OtherARNP LICENSE
IAS61518Medicare UPIN
IA082459Medicare ID - Type UnspecifiedIOWA PROVIDER NUMBER
IA0498329Medicaid