Provider Demographics
NPI:1023045200
Name:SULLIVAN, LAVERNE A (RD)
Entity type:Individual
Prefix:
First Name:LAVERNE
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5244 JEFFRIES LANE
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630
Mailing Address - Country:US
Mailing Address - Phone:812-454-1710
Mailing Address - Fax:260-489-5057
Practice Address - Street 1:4210 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4417
Practice Address - Country:US
Practice Address - Phone:260-489-9009
Practice Address - Fax:260-489-5057
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000748A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered