Basic Information
| Provider Information | |||||||||
| NPI: | 1689602435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JANNA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | WHCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 E WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067528282 | ||||||||
| FaxNumber: | 4062572225 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 CLAREMONT ST | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067528282 | ||||||||
| FaxNumber: | 4062572225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | RN9728 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 4302415 | 05 | MT | MEDICAID |