Provider Demographics
NPI:1588822365
Name:SULLIVAN, AMY (MC RD LD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MC RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11695 S BLACKBOB RD STE B
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1021
Mailing Address - Country:US
Mailing Address - Phone:913-768-6606
Mailing Address - Fax:913-768-6609
Practice Address - Street 1:11695 S BLACKBOB RD STE B
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1021
Practice Address - Country:US
Practice Address - Phone:913-768-6606
Practice Address - Fax:913-768-6609
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1221133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered