Provider Demographics
NPI:1851475578
Name:SULLIVAN, MAUREEN T (RD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:T
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:206-781-6228
Mailing Address - Fax:
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4379
Practice Address - Country:US
Practice Address - Phone:206-781-6228
Practice Address - Fax:206-215-3164
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered