Provider Demographics
NPI:1477915064
Name:SULLIVAN, JULIA B (RD, LD, MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:B
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD, LD, MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 PENNSYLVANIA AVE STE 680
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2133
Mailing Address - Country:US
Mailing Address - Phone:817-250-4235
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 680
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2133
Practice Address - Country:US
Practice Address - Phone:817-250-4235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXDT83553133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT83553OtherLICENSED DIETITIAN
86048739OtherREGISTERED DIETITIAN