MEDICARE: HEATHER BRENNAN SULLIVAN R.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	969683	IL
2	133V00000X	Registered Dietitian	969683	IL

General Provider Information

NPI Number	:	1003123035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER BRENNAN SULLIVAN R.D.

Provider Business Mailing Address
First Line	:	1711 N LARRABEE ST
Second Line	:	2
City	:	CHICAGO
State	:	IL
Zip	:	60614-5621
Country	:	US
Telephone Number	:	773-259-4809
Fax Number	:

Provider Business Practice Location Address
First Line	:	1711 N LARRABEE ST
Second Line	:	2
City	:	CHICAGO
State	:	IL
Zip	:	60614-5621
Country	:	US
Telephone Number	:	773-259-4809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2010
Last Update Date	:	09/13/2010

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