Provider Demographics
NPI:1568586493
Name:SULLIVAN, ANGELA G (MS, RD, CNSD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:G
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, RD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PARK ST
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1125
Mailing Address - Country:US
Mailing Address - Phone:201-370-5656
Mailing Address - Fax:
Practice Address - Street 1:27 MADISON AVE STE 50
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2722
Practice Address - Country:US
Practice Address - Phone:201-370-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL870949133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered