Provider Demographics
NPI:1700913035
Name:SULLIVAN, SANDRA J (DT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DT
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 425
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-0425
Mailing Address - Country:US
Mailing Address - Phone:860-945-3012
Mailing Address - Fax:860-945-9854
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06779-1999
Practice Address - Country:US
Practice Address - Phone:860-945-3012
Practice Address - Fax:860-945-9854
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000778133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered