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NPI Code Detail

MEDICARE: STEPHANIE SULLIVAN RD, LDN

MEDICARE: STEPHANIE SULLIVAN RD, LDN
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 DietitianL006467NC

General Provider Information

NPI Number : 1134979990
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHANIE SULLIVAN RD, LDN
Provider Business Mailing Address
First Line : 103 GRAGG ST
Second Line :
City : BLACK MOUNTAIN
State : NC
Zip : 28711-9202
Country : US
Telephone Number : 610-413-3713
Fax Number :
Provider Business Practice Location Address
First Line : 705 GATE LN STE 202
Second Line :
City : KNOXVILLE
State : TN
Zip : 37909-3521
Country : US
Telephone Number : 865-309-4655
Fax Number : 844-464-0899
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/25/2024
Last Update Date : 03/25/2024

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