Provider Demographics
NPI:1467297291
Name:SULLY, BESSIE-JANE MARIE
Entity type:Individual
Prefix:
First Name:BESSIE-JANE
Middle Name:MARIE
Last Name:SULLY
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 1:263 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-6142
Mailing Address - Country:US
Mailing Address - Phone:503-389-6332
Mailing Address - Fax:503-207-6950
Practice Address - Street 1:263 W EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6142
Practice Address - Country:US
Practice Address - Phone:503-389-6332
Practice Address - Fax:503-207-6950
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200942608RN163WA0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)