Healthcare Provider Details

I. General information

NPI: 1881184349
Provider Name (Legal Business Name): SUSAN BOWLES SULLIVAN RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 VERA RD STE A
LEXINGTON SC
29072-3756
US

IV. Provider business mailing address

407 W MAIN ST
LEXINGTON SC
29072-2661
US

V. Phone/Fax

Practice location:
  • Phone: 803-575-0468
  • Fax:
Mailing address:
  • Phone: 803-996-0312
  • Fax: 803-957-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1595
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: