Healthcare Provider Details

I. General information

NPI: 1023045200
Provider Name (Legal Business Name): LAVERNE A SULLIVAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 FLAGSTAFF CV
FORT WAYNE IN
46815-4417
US

IV. Provider business mailing address

5244 JEFFRIES LANE
NEWBURGH IN
47630
US

V. Phone/Fax

Practice location:
  • Phone: 260-489-9009
  • Fax: 260-489-5057
Mailing address:
  • Phone: 812-454-1710
  • Fax: 260-489-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000748A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: