Provider Demographics
NPI:1124157185
Name:SULLIVAN, KERMIT C III (ATC)
Entity type:Individual
Prefix:MR
First Name:KERMIT
Middle Name:C
Last Name:SULLIVAN
Suffix:III
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 N TURTLE DOVE WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-8363
Mailing Address - Country:US
Mailing Address - Phone:208-442-4354
Mailing Address - Fax:
Practice Address - Street 1:1303 E GREENHURST RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-7216
Practice Address - Country:US
Practice Address - Phone:208-468-7820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-1822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer