Provider Demographics
NPI:1982248308
Name:BAXTER, LEE SULLIVAN (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:SULLIVAN
Last Name:BAXTER
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 SUMMIT PL
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-3155
Mailing Address - Country:US
Mailing Address - Phone:859-613-4618
Mailing Address - Fax:
Practice Address - Street 1:3829 LORNA RD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-7034
Practice Address - Country:US
Practice Address - Phone:205-710-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3073133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered