Provider Demographics
NPI:1326402298
Name:SULLINS, MELINDA (MHS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:SULLINS
Suffix:
Gender:F
Credentials:MHS, RD, LD
Other - Prefix:MRS
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:SULLINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MHS, RD, LD
Mailing Address - Street 1:1823 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2027
Mailing Address - Country:US
Mailing Address - Phone:563-359-9323
Mailing Address - Fax:
Practice Address - Street 1:1823 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2027
Practice Address - Country:US
Practice Address - Phone:563-359-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA080777133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered