Provider Demographics
NPI:1932329646
Name:SLULLIVAN, MARY LOUISE (RD, LD, MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:SLULLIVAN
Suffix:
Gender:F
Credentials:RD, LD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3522 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5732
Mailing Address - Country:US
Mailing Address - Phone:706-796-8739
Mailing Address - Fax:706-796-6075
Practice Address - Street 1:2361 TOBACCO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-9220
Practice Address - Country:US
Practice Address - Phone:706-793-4401
Practice Address - Fax:706-790-4372
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000433133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6842Medicare ID - Type Unspecified