Basic Information
| Provider Information | |||||||||
| NPI: | 1982936092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | HAZLEGROVE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RD, LDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAZLEGROVE | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS. RD. LDN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381055003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014486511 | ||||||||
| FaxNumber: | 9014487097 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381055003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014486511 | ||||||||
| FaxNumber: | 9014487097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2010 | ||||||||
| LastUpdateDate: | 09/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | LDN2202 | TN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
ID Information
| ID | Type | State | Issuer | Description | 103I711459 | 01 | TN | MEDICARE PTAN | OTHER | 1519010 | 05 | TN | MEDICAID |