Provider Demographics
NPI:1467657072
Name:SULLIVAN, PATRICIA MARY (MS RD LDN)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5393 PRINCETON ROAD
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062
Mailing Address - Country:US
Mailing Address - Phone:610-509-9383
Mailing Address - Fax:610-965-7878
Practice Address - Street 1:6083 HAMILTON BOULEVARD
Practice Address - Street 2:
Practice Address - City:WESCOSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18106
Practice Address - Country:US
Practice Address - Phone:610-597-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
3762201OtherAETNA LIFE INSURANCE COMP
PASU1794305OtherHIGHMARK BLUE SHIELD
PASU1794305OtherHIGHMARK BLUE SHIELD