MEDICARE: KRISTINE M SULLIVAN-PETERS RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	37002418A	IN

General Provider Information

NPI Number	:	1033650924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE M SULLIVAN-PETERS RD

Provider Business Mailing Address
First Line	:	76 N IRVINGTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-5702
Country	:	US
Telephone Number	:	317-690-9985
Fax Number	:

Provider Business Practice Location Address
First Line	:	76 N IRVINGTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-5702
Country	:	US
Telephone Number	:	317-690-9985
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2017
Last Update Date	:	09/05/2025

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