Provider Demographics
NPI:1033650924
Name:SULLIVAN, KRISTINE M (RD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1311
Mailing Address - Country:US
Mailing Address - Phone:317-690-9985
Mailing Address - Fax:
Practice Address - Street 1:2700 DOCTOR M.L.K. JR ST.
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208
Practice Address - Country:US
Practice Address - Phone:317-931-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002418A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered