Provider Demographics
NPI:1508315961
Name:SULLIVAN, MARY SHEILA (MED, RD, CSR, LDN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SHEILA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED, RD, CSR, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RAYMOND DR
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-2606
Mailing Address - Country:US
Mailing Address - Phone:413-537-2426
Mailing Address - Fax:
Practice Address - Street 1:16 RAYMOND DR
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-2606
Practice Address - Country:US
Practice Address - Phone:413-537-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA121133V00000X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered