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General NPI Number Information
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NPI Number | 1932329646
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Entity Type | Individual
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Provider Name | MARY LOUISE SLULLIVAN R.D., LD, MA
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Gender | Female
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2361 TOBACCO RD
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City | AUGUSTA
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State | GA
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Zip | 30906-9220
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Country | US
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Telephone | 706-793-4401
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Fax | 706-790-4372
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Provider Business Mailing Address
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Address Line | 3522 HILLTOP DR
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City | AUGUSTA
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State | GA
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Zip | 30906-5732
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Country | US
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Telephone | 706-796-8739
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Fax | 706-796-6075
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | LD000433
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License Number State | GA
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