Provider Demographics
NPI:1063038115
Name:SULLIVAN, STEPHANIE N
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER WAY
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2300
Practice Address - Country:US
Practice Address - Phone:609-653-3913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered