Provider Demographics
NPI:1134979990
Name:SULLIVAN, STEPHANIE (RD, LDN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GRAGG ST
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-9202
Mailing Address - Country:US
Mailing Address - Phone:610-413-3713
Mailing Address - Fax:
Practice Address - Street 1:705 GATE LN STE 202
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-3521
Practice Address - Country:US
Practice Address - Phone:865-309-4655
Practice Address - Fax:844-464-0899
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered