Provider Demographics
NPI:1881184349
Name:SULLIVAN, SUSAN BOWLES (RDN, LD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BOWLES
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2661
Mailing Address - Country:US
Mailing Address - Phone:803-996-0312
Mailing Address - Fax:803-957-2496
Practice Address - Street 1:147 VERA RD STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3756
Practice Address - Country:US
Practice Address - Phone:803-575-0468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1595133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDT1147Medicaid