Provider Demographics
NPI:1821397969
Name:SULLIVAN, SAMANTHA (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 1ST ST APT 312
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-3405
Mailing Address - Country:US
Mailing Address - Phone:575-551-1762
Mailing Address - Fax:
Practice Address - Street 1:2200 1ST ST APT 312
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-3405
Practice Address - Country:US
Practice Address - Phone:575-551-1762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1002021133V00000X
NMLD-0775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered