Provider Demographics
NPI:1639953185
Name:SULLIVAN, MEGAN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12356 S NATCHEZ AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1766
Mailing Address - Country:US
Mailing Address - Phone:708-743-3069
Mailing Address - Fax:
Practice Address - Street 1:12356 S NATCHEZ AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1766
Practice Address - Country:US
Practice Address - Phone:708-743-3069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006570133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered