Healthcare Provider Details

I. General information

NPI: 1467657072
Provider Name (Legal Business Name): PATRICIA MARY SULLIVAN MS RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6083 HAMILTON BOULEVARD
WESCOSVILLE PA
18106
US

IV. Provider business mailing address

5393 PRINCETON ROAD
MACUNGIE PA
18062
US

V. Phone/Fax

Practice location:
  • Phone: 610-597-1512
  • Fax:
Mailing address:
  • Phone: 610-509-9383
  • Fax: 610-965-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN002548
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: