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NPI Code Detail

MEDICARE: LAVERNE A SULLIVAN RD

MEDICARE: LAVERNE A SULLIVAN RD
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
1133V00000XRegistered Dietitian37000748AIN

General Provider Information

NPI Number : 1023045200
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAVERNE A SULLIVAN RD
Provider Business Mailing Address
First Line : 5244 JEFFRIES LANE
Second Line :
City : NEWBURGH
State : IN
Zip : 47630
Country : US
Telephone Number : 812-454-1710
Fax Number : 260-489-5057
Provider Business Practice Location Address
First Line : 4210 FLAGSTAFF CV
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-4417
Country : US
Telephone Number : 260-489-9009
Fax Number : 260-489-5057
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/26/2006
Last Update Date : 07/01/2014

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Directions to “ LAVERNE A SULLIVAN RD” Practice Location

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