Provider Demographics
NPI:1659620581
Name:SULLIVAN, LORI (MS, RD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-1396
Mailing Address - Country:US
Mailing Address - Phone:800-658-0512
Mailing Address - Fax:866-387-4207
Practice Address - Street 1:7 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-1396
Practice Address - Country:US
Practice Address - Phone:800-658-0512
Practice Address - Fax:866-387-4207
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12247539OtherCAQH