Healthcare Provider Details

I. General information

NPI: 1659620581
Provider Name (Legal Business Name): LORI SULLIVAN M.S, R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HILLSIDE DR
SOUTH WINDSOR CT
06074-1396
US

IV. Provider business mailing address

7 HILLSIDE DR
SOUTH WINDSOR CT
06074-1396
US

V. Phone/Fax

Practice location:
  • Phone: 800-658-0512
  • Fax: 866-387-4207
Mailing address:
  • Phone: 800-658-0512
  • Fax: 866-387-4207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: