Provider Demographics
NPI:1457910580
Name:SULLIVAN, OLIVIA GRACE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:GRACE
Other - Last Name:JOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 GATTIS SCHOOL RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2566
Mailing Address - Country:US
Mailing Address - Phone:512-609-0651
Mailing Address - Fax:
Practice Address - Street 1:1000 GATTIS SCHOOL RD STE 150
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664
Practice Address - Country:US
Practice Address - Phone:512-609-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1514133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered