Provider Demographics
NPI:1982936092
Name:SULLIVAN, SARAH HAZLEGROVE (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:HAZLEGROVE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:E
Other - Last Name:HAZLEGROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RD LDN
Mailing Address - Street 1:711 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-5003
Mailing Address - Country:US
Mailing Address - Phone:901-448-6511
Mailing Address - Fax:901-448-7097
Practice Address - Street 1:711 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5003
Practice Address - Country:US
Practice Address - Phone:901-448-6511
Practice Address - Fax:901-448-7097
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN2202133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I711459OtherMEDICARE PTAN
TN1519010Medicaid