Provider Demographics
NPI:1861739963
Name:SULLIVAN, BETHANY ANN
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANN
Last Name:SULLIVAN
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 1:1440 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4921
Mailing Address - Country:US
Mailing Address - Phone:510-778-4662
Mailing Address - Fax:
Practice Address - Street 1:2130 JAMES ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4140
Practice Address - Country:US
Practice Address - Phone:360-207-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61122791363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health