Basic Information
| Provider Information | |||||||||
| NPI: | 1700913035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067950425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609453012 | ||||||||
| FaxNumber: | 8609459854 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OAKVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067791999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609453012 | ||||||||
| FaxNumber: | 8609459854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 000778 | CT | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.